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WELL/PUMP 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 ExPiRES i TEAR FROM uAIE ISSUED <br />JOB ADDRESS West Grant Line Rd/Byron Rd Intersection CITYIZIP Tracy, 95304 <br />ROW A •l`dr'/I F +LZG"rl ; G'✓� <br />CROSS STREET Byron Road APN County PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME San Joaquin County Public Works PHONE 209-468-3000 <br />OWNER ADDRESS 1810 E. Hazelton Avenue CITY/STATEIZIP Stockton, CA 95205 <br />CONTRACTOR V&W Drilling PHONE 209-469-7700 <br />CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATEIZIP Galt CA 94596 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 'yl.,C-57 I i C-61 D-09 L Othef NUMBER 720904 EXPIRATION DATE 04/30/2018 <br />nC%IEST!C WELL SAMpl ING7 General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE I I Domestic/Private -1 Irrigation/Agricultural r i Industrial I I Water Quality Monitoring 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/MOOntcation I I U111el 2 <br />Monitoring Well(S) # of wells I Soil Bonng(s) # of borings Geotechnical # of borings <br />I i Out -Of -Service Well Out -Of -Service Well Renewal -i Cross -Conn tion Repair <br />New PumD -I Pump Replacement i i Pump Repair i Raise Well Casing <br />Drilling Method Mud Rotary ` Air Rotary XAuger Cable Tool Push Point Other <br />Proposed Well Depth 10 It Excavation 6 in diameter 1 Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thicknes Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 10 ft Neat Cement (94 to bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ther <br />Grout Placement Method IL Pumped X <br />ree Fall -1 Other F1 Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller L Pump Contractor-! Other <br />i I Concrete Pedestal i Dimensions: Width ft Length ft Thick in I Christy Box i Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />M/("'�j/IIMUyM� 24 rHOUR <br />ADDVAN/ICE OT CE REQUIRED FOR INSPECTIONS <br />/-PLEASE CALL <br />1 (209) 953-7697"11 � r <br />SIGNED I ■ 17 �.Q/ v �-�/ v ��• � TITLE ftSL a µTV 11 601 [IA. �/ /I "1 f- <br />DEPARTMENT USE ONLY <br />Application Accepted By e <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />V <br />'ElVFD <br />122017 <br />aAL HEALrN <br />Area Employee ID# r I h kl Gl <br />L SPECIAL Well Permit <br />LI WAIVER Received <br />Constructed Weil Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received Check#I <br />B <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />45 <br />s <br />t�I� <br />1 L <br />®c� <br />