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vp M 1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRnm nATt= I -q -cu mn JOB ADDRESS 619 North Hunter Street Crrr/ZIP Stockton/95207 CROSS STREET E. Oak Street APN 139-060-15 PARCEL SIZE N/A LAND USE APPLICATION # OWNER NAME Service First of Northern California PHONE 209-644-4821 OWNER ADDRESS —102 west Bianchi Road CITY/STATE/ZIP Stockton, CA CONTRACTOR V&W Drilling Inc. PHONE 209.469.7700 CONTRACTOR ADDRESS 1133 Blackhurst Drive CfTY/STATE/ZIP Galt, CA 95632 SUBCONTRACTOR Geocon Consultants, Inc. PHONE 925.371.5900 SUBCONTRACTOR ADDRESS 6671 Brisa Street CITY/STATE/ZIP Livermore, CA 94550 LICENSE X C-57 I I C-61 ; i D-09 i I Other NUMBER 720904 EXPIRATION DATE 4/30/2024 DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE I I Domestic/Private I I Irrigation/Agricultural i Industrial ; Water Quality Monitoring iX Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK I I New Well F I Replacement Well r Well Alteration/Modification I I Other I I Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings X Geotechnical 2 # of borings I I Out -Of -Service Well LI Out -Of -Service Well Renewal i I Cross -Connection Repair pq ! 1 New Pump I I Pump Replacement ❑ Pump Repair I I Raise Well Casing WELL CONSTRUCTION C A/ Drilling Method I I Mud Rotary i I Air Rotary X Auger I I Cable Tool I Push Point I Other 1. r I Proposed Well Depth 30' max _ft Excavation 8,, in diameter I I Open Bottom ' Gravel Pack/Gravel Size i Wiigmeter I Conductor Casing in diameter / Conductor Casing Depth ft Sq N J ?O? Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel I I Plastic ' , Stainless Steel Otl� JO Grout Seal Depth 30T ft IX Neat Cement (94 lb bag/5-10 gal water) I Sand CementEq¢a� /Ilr (@ I I Bentonite (20% solids) Other qC4 1Epq� TqC Grout Placement Method I Pumped al Free Fall .Other I to: l I Retardant /Accelerator (name) PEDESTAL Installed By I I Driller i Pump Contractor Other Concrete Pedestal I IDlmensions: Width ft Length ft Thick in Christy Box I 1 Stove Pipe PUMP I7 Submersible[. 1 Turbine I I Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. iA1NI.NIUh4 24 HOUR AI)VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL. (209) 953-7697 DE ARTMENT USE ONLY �� Application Accepted By Date n� Area 19 5 (,,��—• Employee ID# Grout Inspection By „g�u.��9 (I (,n,,'7 Date ❑l 5PEC�IAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit! Invoice # Well ID# Codes Info Cash Remitted ice Rig4est # 777) V ElID043-06 10125/2021 ( l'�/(,z3a5l Pap l oft Wc11IPump Pcrmil 'T J