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f <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENT L HEALTH DEPARTMENT 1868 EAST H ZELTON AVENUE-STOCKTON CA 95205 - (209) 468.3420 <br />NUN-KEFUNDABLL PERMIT <br />GALL LUtItiOJ-/OUI FOR INSPECI IONS <br />tAYIKtJ T TEAR FROM Ll IE ISSUED <br />JOB ADDRESS <br />fa -4 IE Scotts Ave <br />(BNSF ROW) .�.—_ <br />CITY/ZIP <br />Stockton, CA <br />CROSS STREET <br />S Pilgrim St <br />APN 15130002 <br />PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME <br />/�� <br />BNSF gl� 11 h<10)1 /J <br />d ✓Gin fc, Fe <br />R R co <br />PHONE <br />OWNER ADDRESS <br />10 <br />720 B St <br />CITY/STATE2IP Stockton, CA 95205 <br />CONTRACTOR <br />Kleinfelder <br />CONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 <br />SUBCONTRACTOR Taber Drilling <br />PHONE 661-302-2054 <br />CITY/STATE2IP Stockton, CA 95206 <br />PHONE 916-371-8234 <br />SUBCONTRACTOR ADDRESS 536 Galveston St CITY/STATE/ZIP West Sacramento, CA 95691 <br />LICENSE A-57 7 C-61 7 D-09 7 Other NUMBER 969927 EXPIRATION DATE 2/28/2021 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE D Domestic/Private -1 Irrigation/Agricultural F Industrial - Water Quality Monitoring Soil Sampling/Characterization <br />Li Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK [] New Well L Replacement Well a Well Alteration/Modification / Other CPT <br />0 Monitoring Well(s) # of wells /Soil Boring(s) 2 # of borings Geotechnical 1 CPT # of borings <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal L Cross -Connection Repair /y <br />Li New Pump a Pump Replacement u Pump Repair L Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method /Mud Rotary n Air Rotary /Auger n Cable Tool F Push Point / Other Direct Push r FN OqQ <br />Proposed Well Depth 150 (max) ft Excavation 8 (max) in diameter 7 Open Bottom n Gravel Pack/Gravel Size., <br />ilt <br />L) Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 7 Steel ❑ Plastic ❑ Stainless Steel - Other <br />Grout Seal Depth 150 (max) ft / Neat Cement (94 lb bagl5-10 gal water) C Sand Cement sack mix17 gal water <br />Bentonite (20% solids) fl Other <br />Grout Placement Method Pumped Free Fall XOther Tremie n Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller D Pump Contractor -1 Other <br />Concrete Pedestal rlDimensions: Width ft Length ft Thick <br />In u Christy Box ❑ Stove Pipe <br />PUMP 0 Submersible[] Turbine -1 Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Datea <br />Grout Inspection By Datev, <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area S�G^r li►� Employee ID# In S <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />It <br />Ln <br />m <br />0 <br />0 <br />N <br />HDO43-0610/2 202 age oft <br />Well / ump Permit <br />AmountRemitted <br />HDO43-0610/2 202 age oft <br />Well / ump Permit <br />