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JOB ADDRESS 0 1-580 at International Parkway Overcrossing cr-ryizip Tracy 95377 <br />Patterson Pass Road ApN Nelq, 30q I 000 PARCEL SIZE N/A CROSS STREET g LAND USE APPLICATION # _ <br />Caltrans District 10 PHONE 209.948.7891 OWNER NAME <br />1976 E Charter Way/MLK Jr. Blvd CITY/STATE/ZIP Stockton, CA 95201 OWNER ADDRESS <br />V8rW Drilling Inc. 209.469.7700 <br />CONTRACTOR PHONE <br />1133 Blackhurst Drive CITY/STATE /ZIP Galt, CA 95632 CONTRACTOR ADDRESS <br />SUBCONTRACTOR Geocon Consultants, Inc. 925.371.5900 PHONE <br />6671 Brisa Street CITY/STATE/ZIP Livermore, CA 94550 SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 C-61 D-09 Other NUMBER 720904 EXPIRATION DATE 4/30/2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X 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 Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings X Geotechnical yt, # of borings <br />Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair P4 y <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 30' max ft Excavation 8" in diameter Open Bottom Gravel Pack/Gravel Size 04pRaller <br />Conductor Casing in diameter / Conductor Casing Depth ft 4 0 Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel OtOt < _. <br />Grout Seal Depth Kr — ft X Neat Cement (94/b bag/5-10 gal water) Sand Cement <br />, <br />P Bentonite (20% solids) Other T <br />Grout Placement Method Pumped X Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in Christy Box 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 />Application Accepted By .......--7""/--/--- Date 9//3 b Area Employee ID# A <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />--- Date 6/1 21 "2:2- Constructed Well Depth ft , Soil Boring Inspection By <br />COMMENTS --ri evv,de v o be us rci if deeper Aar fee+ or I's .0 <br />en coon fer 'eel • ilvidm-at a- 6s- 4 • r •,:i a 4-14- 4sr/S 2. SAIZZ <br /> zz.thdpvciier :SS3HOCIV 3.LIS I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUND4BLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />PE <br />Codes <br />SC <br />Info <br />Received <br />,i3a. 6/ <br />C heck#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Rectilest # Invoice # Well ID# <br />437R /SO ViSA.- # /06ci kiln 1,01900qS174., <br />Page 1 of 2 <br />/ /5—a 75-- Cov.,k0 2(i 3 <br />Well / Pump Penult <br />57 2., 0 <br />EHD043-06 10/25/2021