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I WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIKE5 7 YEAR FROM UATE ISSUED <br />JOB ADDRESS C293S Cwq�}an 3?9��`8$°,��1-9i-9t'h3° CITY/ZIP Stockton, CA, 95206 <br />CROSS STREET Navy Dr/W Washington St APN 14-502-007 PARCEL SIZE 9.2 acr LAND USE APPLICATION# Unknown <br />OWNER NAME Melanie Rodriguez contact person: Gloria Ruiz PHONE (209) 946-0246 ext 8281 <br />OWNER ADDRESS 2201 W. Washington St CITY/STATE/ZIP Stockton, CA 95219 <br />CONTRACTOR Gregg Drilling, LLC PHONE (925) 313-5800 <br />CONTRACTOR ADDRESS 950 Howe Road CITY/STATE/ZIP Martinez, CA 94553 <br />SUBCONTRACTOR Kleinfelder, Inc <br />SUBCONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 <br />LICENSE ■ C-57 ❑ C-61 ❑ D-09 ❑ Other, <br />CITY/STATE/ZIP <br />PHONE (209) 993-2269 <br />Stockton, CA 95206 <br />NUMBER 1044456 EXPIRATION DATE 09/30/2022 <br />DOMEsnc WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) a Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ■ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Mod cation ❑ Other <br />Check#/ Amount Date Permit/ Invoice # Well ID# <br />Cash Remitted Service Re uest # <br /># of borings <br />❑ Monitoring Well(s) # of wells 11 Soil Boring(s) ■Geotechnical <br />() 11 A <br />One 1 # of borin�� <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />C`c� <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />SAN <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 11 Push Point 11 Other <br />in <br />Proposed Well Depth 40 ft Excavation S in diameter ❑Open Bottom ❑Gravel Pack/Gravel <br />Size HFAeAAr <br />❑ Conductor Casing in diameter / Conductor Casing Depth It <br />h pEpMF,yo <br />T <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel <br />❑ Other q <br />Grout Seal Depth 40 ft ■ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement <br />sack mix/7 gal wate <br />❑ Bentonite (20% solids) ■Other up to 5% bentonite <br />Grout Placement Method ■ Pumped ❑ Free Fall ■ Other Tremie Full -Depth ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in D Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ 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 TNSPECTTONS - PLEASE CALL (209) 953-7697 <br />/ DEPARTMENT USE ONLY <br />Application Accepted By e Date Sas' a."z <br />Grout Inspection By <br />Pump Inspection By of <br />Soil Boring Inspection By dC <br />COMMENTS <br />Date <br />Date <br />Date O 'Z9 fL2 <br />Area 115f_00 ""Employee ID# M-5 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE Sc Received <br />Codes Info BV <br />Check#/ Amount Date Permit/ Invoice # Well ID# <br />Cash Remitted Service Re uest # <br />y37a o <br /># y s <br />EHDO43-06 04/07/2022 L �,Iy/ j9Page I of 2 Well / Pump Permit <br />J <br />