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I 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 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />'JoB ADDRESS _ 1881 East Market Street CITY/ZIP Stockton/95205 <br />CROSS STREET S A Street APN 153-090-580-000 PARCEL SIZE 1312 aC LAND USE APPLICATION # <br />OWNER NAME United Charter, LLC, Raymond Zhang, Managing Member PHONE (415) 269-6033 <br />OWNER ADDRESS 1617 East Main Street - _ _ CITYISTATEIZIP Stockton, CA 95205 <br />CONTRACTOR V&W Drilling PHONE (209) 469 7700 <br />CONTRACTOR ADDRESS _1133 Blackhurst Drive CITYISTATEIZIP Galt/CA/95632 <br />SUBCONTRACTOR Wallace -Kuhl & Associates PHONE (916) 372-1434 <br />SUBCONTRACTOR ADDRESS 3050 Industrial Blvd. CITYISTATEIZIP West Sacramento/CA/95691 <br />LICENSE XC -57 C-61 C D-09 i.. Other NUMBER 720904 EXPIRATION DATE 4/30/24 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE C Domestic/Private - Irrigation/Agricultural Industrial Water Quality Monitoring XSOII Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK i7 New Weil Replacement Well ❑ Well Alteration/Modification Other <br />Monitoring Well(s) # of wells � Soil Boring(s) # of borings XGeotechnical 7 # of borings <br />Out -Of -Service Well a Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement �! Pump Repair Raise Well Casing _ <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary X_/auger Cable Tool I i Push Point Other <br />Proposed Well Depth 15 ft Excavation in diameter i . Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ` ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 15 ft XNeat Cement (94 !b Bagl5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) '-i Other IR )XIM-MIN_ <br />Grout Placement Method P Pumped XFree Fall -1 Other Tremle If Water -_ Retardant / Accelerator (name) <br />PEDESTAL Installed By ii Driller Pump Contractor Other <br />C Concrete Pedestal _Dimensions: Width It Length ft Thick <br />in Christy Box Stove Pipe <br />PUMP _ C Submersible - Turbine _, Other HP Pump Set ftStanding WatSANv ' ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the folloNqif <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existirIl �11 <br />w5" <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domes N <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />sl17; ? 4 HCtt'R:�D\ .1\('E NO"rl('F: lt1:C11'IREU fOR t\SPE("I'!!i' - <br />�? J DEPARTMENT USE ONLY j 1 <br />Application Accepted By �� <br />_ q l� L -_ Date Area l % ( �� 40/ Employee ID#,� <br />Grout Inspection By it Date 1 ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By _ _r Date Constructed Well Depth _ ft <br />COMMENTS n i ��iA l iYJI�{�[�Ll (�i�'71� �t �C) \ J ,Ol� -t LA(-Ol.)� <br />Y <br />PE <br />Codes <br />Sc Received Check#/ <br />Info B Cash <br />Amount Permit/ <br />Remitted Date Service uest # Invoice # Well ID# <br />' <br />I� <br />EHD043.06 1025,'2021 Pnue 1 ort Well Pump 11 r "t <br />4 11 (z2 <br />