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CONTRACTOR V & W. Drilling Inc. PHONE 209-369-9600 <br />BILLING PARTY: El OWNER 0 CONTRACTOR Fif' SUBCONTRACTOR/CONSULTANT <br />JOB ADDRESS 8008 W. Schulte Road cm/zip Tracy, 95304 <br />CROSS STREET S. Chrisman Road APN 252-040-01 PARCEL SIZE 2 acre-AND USE APPLICATION* <br />OWNER NAME k at/ WA, (1.- it Cedd- C its-1--e / 0 PHONE <br />OWNER ADDRESS Z 2-31 GO -k11.00 CITY/STATE/ZIP --C441. ..4,C.,-- <br />CONTRACTOR ADDRESS 1133 Blackhurst Drive cnyisTATErzip Galt. CA, 95632 <br />SUBCONTRACTOR/CONSULTANT Mid Pacific Engineering PHONE 916-767-8082 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 840 Embarcadero Drive, Suite 2 /STATEMP Q._ West Sacramento, CA 9560 s <br />LICENSE VC-57 C C-61 0 D-09 C Other NUMBER 720904 EXPIRATION DATE 4/30/2022 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Califon Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring !'Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />L v‘iP <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />kiriki Rem mineekt c DceRcr AAAAA .••• i/Ak.11 CY:1MCV 4 VGAM ...M 1Are I.0 JCJ <br />TYPE OFWORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells NE( Soil Boring(s) I #01 borings 'NI Geotechnical C ot borings <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary ''Auger 3 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth 50 ft Excavation fi In diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Welt Casing Diameter in Thickness/Gauge/ASTM Sched 3 Steel 0 Plastic 7 Stainless Steel 0 Other <br />Grout Seal Depth ft Q' Neat Cement (94/b bag/5-10 gal water) 0 Sand Cement sack mIx17 gal water <br />0 Bentonite (20% solids) C Other <br />Grout Placement Method n Purnned n Free Fall 0 Other El Retardant / Accelerator Inamel <br />FLVIL_STAL Installed By C Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal 00Imensions: Width ft Length <br /> <br />ft Thick in 0 Christy Box C Stove Pipe <br />E211LP CI Submersible 0 Turbine 0 Other HP Pump Sets 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 />MINIMUltNIVI&JR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> T TLE Ri si•3; NQA,C. DATE Si 1 SIGNED <br />et <br />DE t -TMENT <br />Application Accepted By 1 / 41•11 Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspec on By <br />COMMENTS <br />5- Employee ID# <br />7 SPECIAL Well Permit <br />G WAIVER Received <br />onstructed Well De h <br />f <br />PE <br />Codes <br />SC w <br />Info <br />Received t heckill Amount <br />Cash Remitted <br />Permit/ Invoice # Well ID# i 4epci_ce 12,eguest # ,_ <br />11317 150 deedrt if 5-6 1‘7 <br />1Dat <br />it174 irNi n01201-4 1 1 T , , , <br />ENO 43-08 Sill/2019 6m-c. izsst2_30.3- WELL iPUMP PERMIT <br />4 12-5-5,3/-73