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It . <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT CALL ZUy VbJ-tb9[ FOR INSPECTIONS tXF'IKt_5 1 YEAR FROM UATE ISSUED <br />JOB ADDRESS 1181-1199 S. Wilson Way CITY/ZIP Stockton 95205 —7 <br />CROSS STREET Anderson Street APN PARCEL SIZE <br />OWNER NAME City Of Stockton <br />OWNER ADDRESS 22 East Weber Avenue <br />CITY/STATE/ZIP <br />-LAND USE APPLICATION # <br />PHONE 209-937-8411 <br />Stockton, CA 95202 <br />CONTRACTOR ENGEO Incorporated PHONE 925-719-0822 <br />CONTRACTOR ADDRESS 17278 Golden Valley Parkway CITY/STATE/ZIP Lathrop, CA 95330 <br />SUBCONTRACTOR West Coast Exploration PHONE 209-985-7541 <br />SUBCONTRACTOR ADDRESS P.O. Box 133 CITY/STATE/ZIP Escalon, CA 95320 <br />LICENSE X C-57 I C-61 I D-09 I. Other NUMBER 870761 EXPIRATION DATE 1/31/2024 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE I Domestic/Private I Irrigation/Agricultural I Industrial I Water Quality Monitoring I I Soil Sampling/Characterization <br />[I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well I Replacement Well ❑ Well Alteration/Modification ❑ Other <br />Date <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings X Geotechnical <br />4 # of borings <br />❑ Out -Of -Service Well U Out -Of -Service Well Renewal I Cross -Connection Repair <br />F. New Pump Pump Replacement Ll Pump Repair I Raise Well Casing <br />Pump Pump Replacement Pump Repair I Raise Well Casing�� <br />WELL CONSTRUCTION <br />�rr <br />Drilling Method ❑ Mud Rotary I Air Rotary X Auger I Cable Tool I Push Point Other <br />_ CiQ n . <br />Proposed Well Depth 20-30 ft Excavation 4 in diameter I Open Bottom I Gravel Pack/Gravel <br />Size qN in diam to <br />f' Conductor Casing in diameter / Conductor Casing Depth ft <br />HE N�/ q QN/ <br />� RAN N C <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel I Plastic I Stainless Steel <br />I ] Other <br />Grout Seal Depth 20-30 ft X Neat Cement (94 Ib bag/5-10 gal water) I Sand Cement <br />sack mixt nal r>n <br />1 Bentonite (20% solids) I Other <br />Grout Placement Method i Pumped I Free Fall X Other Tremie Retardant / Accelerator (name) <br />PEDESTAL Installed By I Driller I Pump Contractor I Other <br />I Concrete Pedestal I Dimensions: Width ft Length ftThick <br />n I Christy Box I Stove Pipe <br />PUMP I SubmersibleL Turbine I 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 />MINIMC:M 24 110E R ADN ANCE NOTICE RLQt IRFD FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DTMENT USE O LY <br />Application Accepted By Date `ZD Z -Area Employee ID# <br />Grout Inspection By Date D SPECIAL Well Permit <br />Pump Inspection By ate Ll WAIVER Received <br />Soil Boring Inspection By / ! ti �L-�� Date l� 22 Constructed Well Depth <br />COMMENTS <br />ft <br />�r <br />ry <br />PE SC Received Check#/ Amount <br />Codes Info B Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Re uest # <br />_ 6 t r2 <br />EHD043-06 04/07/2022 �/'�� / / `� Page I of/Z� Well ; Pump Permit <br />