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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 /> NON-REFUNDABLE PERMITCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS SE corner o Elgh Wile Road and West Ln cITY/zIP Stockton/95206 m <br /> D <br /> CROSS STREET Eight Mile Road APN 120-020-02,-03,-17,-18,-19,-22,-23 PARCEL SIZE 200.16 LAND USE APPLICATION# o <br /> z <br /> M <br /> OWNER NAME John Tomasello PHONE 530-208-8482 W <br /> OWNER ADDRESS 18958 Louis Road CITY/STATE/ZIP Grass Valley,CA 95945 <br /> CONTRACTOR V&W Drilling PHONE 209-369-9600 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATE/ZIP stockton,CA/95632 <br /> SUBCONTRACTOR Mid Pacific Engineering PHONE 916-516-2116 <br /> SUBCONTRACTOR ADDRESS 840 Embarcadero Drive,Suite 20 CITY/STATE/ZIP West Sacramento,CA,95605 <br /> LICENSE VC-57 E C-61 ❑ D-09 ❑ Other NUMBER 720904 EXPIRATION DATE <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 ❑ Well Alteration/Modification ❑ Other <br /> #of borings #of borings <br /> I. Monitoring Well(s) #of wells ❑ Soil Boring(s) Geotechnical 29 <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION / <br /> Drilling Method 11 Mud Rotary, 4- Air Rotary pfd Auger 11 Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth�_ft Excavation in diameter ❑ 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 E Steel El Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth IS— �D ft (Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped VFree Fall Other Tremie ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller E Pump Contractor ❑ Other <br /> Concrete Pedestal EI Dimensions:Width ft Length ft Thick <br /> �in Christy Box Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine I i 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 /> MININIt NI 24 1101 R:SDN kN('I(1,0FICE RE01 IRIA)FOR INSI11.1 I IONS-PLEASE(ALL(209)953-7697 <br /> PA TMENT USE ONLY <br /> Application Accepted By,�— D Date , -)XZ' Area v Employee ID# - a� <br /> Grout Inspection By Date SPECIAL Well P <br /> Pump Inspection By Date WAIVER Receive M�N� <br /> Soil Boring Inspection By Date (o Z '7/( Constructed Well Depth y ft <br /> COMMENTSAwl <br /> PE SC Received Check#/ Amount Dae Permit/ InvV�IMC( l II ID# <br /> Codes Info B v I Cash Remitted Service Re uest# R <br /> t <br /> IiIIDU4 3-060d,07'3032 ��� � Iy�I�l.QS,�.�(.Q Weil/Pump Pcnmi <br />