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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 />NUN-111:1hUNDABLE VERMIT CALL <br />tiro XT -4, W-+- c+..,..,+ <br />ADDRESS <br />STREET E. Oak Street <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP Stockton/95207 <br />APN 139-060-33 PARCEL SIZE N/A LAND USE APPLICATION # <br />OWNER NAME Service First of Northern California PHONE 209-644-4821 <br />OWNER ADDRESS _,102 West Bianchi Road CITY/STATE/ZIP Stockton, CA <br />CONTRACTOR V&W Drilling) Inc. PHONE 209.469.7700 <br />CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATE/ZIP Galt, CA 95632 <br />SUBCONTRACTOR Geocon Consultants, Inc. <br />SUBCONTRACTOR ADDRESS 6671 Brisa Street <br />LICENSE X C-57 C-61 I I D-09 I I Other <br />PHONE 925.371.5900 <br />CITY/STATE/ZIP Livermore, CA 94550 <br />NUMBER 720904 EXPIRATION DATE 4/30/2024 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private i ; Irrigation/Agricultural I I Industrial 1. Water Quality Monitoring X Soil Sampling/Characterization <br />❑ Public Water System Stockton, CA <br />If different from Owner: Water System Name Contact Name or Phone Number <br />YPE OF WORK I New Well I t Keplacement Well 1 ! Well Alteration/Modification I I Other <br />❑ Monitoring Well(s) # of wells I Soil Boring(s) # of borings X Geotechnical <br /># of borings <br />��'3 <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal I I Cross -Connection Repair <br />CI New Pump I Pump Replacement I Pump Repair I_i Raise Well Casing^f <br />/ <br />WELL CONSTRUCTION <br />/ <br />Drilling Method I i Mud Rotary is Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 30' max _ft Excavation 8" in diameter I I Open Bottom I I Gravel Pack/Gravel Size r <br />I I Conductor Casing in diameter / Conductor Casing Depth ft <br />�qN JOJO < <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel Plastic I Stainless Steel <br />— <br />I Otfit� EN qQ(1/ <br />Grout Seal Depth 30 ft IX Neat Cement (94 Ib bag/5-10 gal water) 1 Sand Cement <br />sac <br />I I Bentonite (20% solids) i Other <br />Grout Placement Method I Pumped X Free Fall Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By I I Driller ! I Pump Contractor Other <br />I Concrete Pedestal iiDimensions: Width ft Length ft Thick <br />in ❑ Christy Box L_) Stove Pipe <br />PUMP ❑ Submersible) I Turbine I I Other HP Pump Set ft $f �� ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the �ltemTi. GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing we s�Ei*uctures, <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 />MIN) NJU67 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />141L-,�� DEPARTMENT U E ONLY <br />/ <br />Application Accepted By ECh� Date Z✓ `� Area 1 9 i�� Employee Ill <br />Grout Inspection By /rzt::.;sem: ! �. �, L„ Date liTlI Z_ ElSPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By _ <br />COMMENTS 742a <br />Date <br />Constructed Well Depth <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info By, Cash Remitted ervice R uest # <br />7 7'T54_ 3 <br />enuvv-oe wiz)rzoz i Page l of 2 Wel l / Pump Permit <br />l`t��236Fj <br />Cil <br />rn <br />1 <br />M <br />g <br />M <br />M <br />y <br />C <br />T <br />GW <br />