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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />1YVIV-MLI-UIVUACLt r'tKM11 <br />OB ADDRESS <br />%,ALL <br />. /S. Van Buren St. <br />tics-IbV( FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP Stockton / 95203 <br />(CROSS STREET W. Market St./S. Van Buren St. APN 137-360-26 PARCEL SIZE + � t.I LAND USE APPLICATION # <br />OWNER NAME Stockton Unified School District - Contact: Lewis Pablo, Engineering Tech. PHONE 209.933.7045, Ext. 2344 <br />OWNER ADDRESS 1944 N. El Pinal Drive <br />CONTRACTOR V & W Drilling - Contact: Karli Stroing <br />CONTRACTOR ADDRESS 1133 Blackhurst Drive <br />CITY/STATE/ZIP Stockton, CA 95205 <br />PHONE 209.981.7755 <br />CITY/STATE/ZIP Galt, CA 95632 <br />SUBCONTRACTOR Condor Earth -Contact: Ron Skaggs, CAPE #44588 /GE #2295 PHONE 209.601.1430 (cell) <br />SUBCONTRACTOR ADDRESS 189 Frank West Circle, Suite I CrTY/STATE/Z1P Stockton, CA 95206 <br />LICENSE X C-57 ❑ C-61 ❑ D-09 0 Other NUMBER 720904 EXPIRATION DATE 04/30/2022 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ 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 <br />1 Monitoring Well(s) # of wells <br />❑ Out -Of -Service Well <br />D New Pump ❑ Pumo Reolacement <br />❑ Well Alteration/Modification ❑ Other <br />❑ Soil Borings) # of borings X Geotechnical <br />❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />4 # 01 bodng�A� <br />CIC'. <br />WELL CONSTRUCTION ' �� • <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other SANIn <br />Proposed Well Depth 5 to 20 ft Excavation 4 1/2 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size jg err <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft /y <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other OFpgR� . <br />Grout Seal Depthfull depth ft X Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal wa't' e0 <br />❑ Bentonite (20% solids) )X Other Tremie <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant 1 Accelerator (name) <br />eDEs AL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />In ❑ Christy Boz ❑ 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 INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />' ' c k i-pY3 <br />Application Accepted By �nn-�+ — Date a ho �`' Area r " Employee ID# ?r, <br />Grout Inspection By /L �� Date 2- ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />Sc Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Info Cash Remitted i Service Request # <br />EHD043-06 1025/2021 <br />Pqg 1 ort <br />�rti � 13B7�z9y� f <br />Wc11 / Pump P—it <br />M <br />D <br />0 <br />0 <br />m <br />m <br />N <br />%, <br />1 <br />