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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 />vr�-r�crunvAOLC t-[ItlYll I _ _ <br />11 -ALL <br />JOB ADDRESS West Hammer Lane <br />CROSS STREET <br />OWNER NAME <br />Mariners Dr. <br />City of Stockton <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED_ <br />CITY/ZIP Stockton, 95219 <br />No parcel number. Public Thoroughfare <br />APN seeattae PARCEL SIZE LAND USE APPLICATION # <br />I Lk CL c0 .hed site plan 11 5o f y — — <br />PHONE <br />ADDRESS City Hall, 425 N. EI Dorado St. CITYISTATEIZIP Stockton, CA 95202 <br />CONTRACTOR V&W Drilling <br />CONTRACTOR ADDRESS 1133 Blackhurst Drive <br />SUBCONTRACTOR Wallace -Kuhl & Associates <br />SUBCONTRACTOR ADDRESS 3050 Industrial Blvd. <br />LICENSE X C-57 lJ C-61 D-09 .1 Other <br />CITY/STATEIZIP <br />PHONE _ (209) 469-7700 <br />Galt, CA, 95632 <br />PHONE (916) 372-1434 <br />CITYISTATEIZIP West Sacramento, CA, 95691 <br />NUMBER 720904 EXPIRATION DATE 4/30/24 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria 143911 D Dibromochlnrnnronnna (A AQ)i n nr-J, reaoz% <br />NTENDEDUSE Domestic/Private F Irrigation/Agricultural -i Industrial Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water <br />If different from Owner Water System Name Contact Name or Phone Number <br />.+ �.-.• .vcn a roc Pia�cnicnr vven u vvell ill feraimni Viii cation Other <br />C Monitoring Well(s) # of wells D Soil Borings) I # of borings X Geotechnical 2 # of borings <br />D Out -Of -Service Well �] Out -Of -Service Well Renewal C Cross -Connection Repair <br />C New Pump (J Pump Replacement :1 Pump Repair D Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method _ Mud Rotary n Air Rotary (Auger Cable Tool . Push Point Other <br />Proposed Well Depth 5-10 ft Excavation in diameter 11 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 C Plastic Stainless Steel �7� <br />Q <br />Grout Seal Depth 5=1-0 ft X Neat Cement (94 lb bag/5-10 gal water) D Sand Cement ter <br />Bentonite (20% solids) Other ®C/�CI\/C11 <br />Grout Placement Method :-Pumped R Free Fall Other Tremie if water C Retardant / Accelerator (name) <br />PEDESTAL <br />in <br />Installed By i Driller Pump Contractor Other <br />Concrete Pedestal ;Dimensions: Width fl Length <br />Christy Box Stove Pipe <br />It Thick <br />PUMP Submersible, Turbine -- Other HP Pump Set ft Standing <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the <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 />AINIMIll 24 I101'R AD%':%X( IF NOTICE REQUIRED FOR <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 1 �/ �� Area ✓((-s <br />_ Employee ID# Nil <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By �" of Date G WAIVER Received <br />Soil Boring Inspection By / r �^ Lr Date ZC'' 2 Constructed Well Depth K <br />COMMENTS <br />cnwanwo �ua� tuts Pape Ihof of 2 p'ell: Puny> Perron <br />T <br />y <br />m <br />a <br />0 <br />0 <br />m <br />N <br />N <br />