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I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4684420 NUN-KEFUNDABLE PERMIT UALL LUy U0J-[bt11 FOR INSPECTIONS CJCF'IKtJ 1 TEAR FROM DATE ISSUED JOB ADDRESS 5 West 6th Street CITY/ZIP Tracy CROSS STREET N Central Avenue APN 235-069-11 PARCEL SIZE N/A LAND USE APPLICATION # OWNER NAME COSE DON A & COSE DARLENE A TR PHONE67-147 V � iG /[5�/� OWNER ADDRESS _ �OrN ` CITYISTATE/Z1P 7 Y7� ,��j CONTRACTOR V&W DrillingInc. PHONE 209.469.7700 CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATE/ZIP Galt, CA 95632 SUBCONTRACTOR Geocon Consultants, Inc. PHONE 925.371.5900 SUBCONTRACTOR ADDRESS 6671 Brisa Street LICENSE X C-57 a C-61 j D-09 Other CITY/STATE/ZIP Livermore, CA 94550 NUMBER 720904 EXPIRATION DATE 4/30/2022 DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE Domesfic/Private i � Irrigation/Agricultural Industrial .:i Water Quality Monitoring X Soil Sampling/Characterization Public Water System If different from Owner Water System Name Contact Name or Phone Number TYPE OF WORK ; New Well ri Replacement Well Well Alteration/Modification F-1 Other Monitoring Well(s) # of wells Soil Boring(s) # of borings X Geotechnical 1 # of borings Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair New Pump Pump Replacement Pump Repair Raise Well Casing WELL CONSTRUCTION q rM zjv Drilling Method _ 1 Mud Rotary Air Rotary X AugerCable Tool Push Point Li Other Proposed Well Depth 30' max _ft Excavation 8" in diameter i Open Bottom O Gravel Pack/Gravel Size I�1�7 Conductor Casing in diameter / Conductor Casing Depth ft C Well Casing Diameter in Thickness/Gauge/ASTM Sched ISteel Plastic - Stainless Steel Othet rel T Grout Seal Depth 30 ft XNeat Cement (94 Ib bag/5-10 gat water) Sand Cement! SA nr ��k mix17 galQQ Bentonite (20% solids) OtherEAI Grout Placement Method !_ Pumped X Free Fall 1 Other Retardant / Accelerator (name)rllALT. n1.�UNh1EfvTUN PEDESTAL Installed By Driller Pump Contractor Other Concrete Pedestal -.Dimensions: Width ft Length ft Thick �in Christy Box ' Stove Pipe PUMP Submersibles i Turbine - 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. NIINI;Nit \I 24 1101 H ADVANCE NOTICL REQUIRED FOR INSPECHONS - PLEASL CA Ll. 1209) 953-7697 DEPARTMENT USE ONLY f� Application Accepted By �� Date s3 0 Area SIS bz kf-D), Employee ID# A 5 Grout Inspection By 4%!U.' .v A Q._'� Date _ `L- ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS-ri'OMle Pine, -1c, 6e v5,e_ ' ilephP/ 11'hQ0 30 491 nr 6� �, r1W';'iCJ1n/L�+E7Y 1 S PE SC Received Check#/ Info BY— Cash Amount Permit/Codes Remitted Date Service R uest # Invoice # Well ID# -13-79 sos� 22 U� EHDM3-061(125,2021 Pa c 1 .12 Ncll N fermi I�1I)LI g >s 3/zs * Z