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T f <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-RFFIINf1AR1 F PFRMIT CALL (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 19 West 6th Street CITY/ZIP Tracy <br />AT ('antral A-iraniva 235-069-15 <br />1:R055 JiREEf "- "' HMIV PARCEL JIZE) LAND USE HPPLICATIUN if <br />OWNER NAME COSE DON <br />%A & COSEQDARL}E� NE A TnR PHONE eA��y��/- %�/q`�.�T �y [� <br />OWNER ADDRESS �� � I Fc9SJ Ve,IDi[t, P -el CITY/STATE/ZIP 2� a. `1101 r / <br />CONTRACTOR V&W Drilling Inc PHONE 209.469.7700 <br />1133 BI-ac!,h'--st Tlri.rc (`-n1+ /-A OC417 <br />CONTRACTOR ADDRESS "''""'""''� "` "' ' " CITYISTATEIZIP � <br />SUBCONTRACTOR Geocon Consultants, Inc. PHONE 925.371.5900 <br />SUBCONTRACTOR ADDRESS 6671 Brisa Street CITY/STATE/ZIP Livermore, CA 94550 <br />LICENSE X C-57 D C-61 D-09 i. Other NUMBER 720904 ExPIRATION DATE 4/30/2022 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well -i Replacement Well ❑ Well Alteration/Modification n Other <br />hAnnitnrinn WPIIICI# of wallc Rnil Rnrinnfcl # of borings Y r�Pntorhniral X3 # of bonrg� <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair R q YM <br />New Pump ❑ Pump Replacement Pump Repair n Raise Well Casing <br />WELL CONSTRUCTION /� <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other RA <br />Proposed Well Depth 301 max _ ft Excavation 8" in diameter l Open Bottom Gravel Pack/Gravel Size S, in to e <br />Conductor Casino in diameter / Conductor Casino DeDth It F AQtj <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched -)Steel '1 Plastic CI Stainless Steel tJ NV/RO iA CO <br />Grout Seal Depth 30T' ft XNeat Cement (94 Ib bagl5-10 gal water) Sand Cement sack'M <br />Bentonite (20% solids) Other <br />Grout Placement Method :-i Pumped % Free Fall .. Other _! Retardant / Accelerator (name) <br />PEDESTAL Installed By . i Driller ❑ Pump Contractor I Other <br />Concrete Pedestal 'Dimensions: Width ft Lena_th ft Thick <br />lin Christy Box j Stove Pipe <br />PUMP -i Submersible Turbine -; 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 />♦ __.e _._1._. _._ r_. a___._.:_1 __-_n <br />!-cS..uuawq auuuou .n. rr c.., _. .u_reucuvr nub .nae. .r cn.e va. ou. en__c r_n.c.-w2nn! _nud:u_o <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC"I'IONS- PLEASE CALL (209I 953-7697 <br />DEPARTMENT USE ONLY Q <br />Application Accepted By � Z -Z - Date 3 3(7 as Area Si0d4z j7 Employee ID# A <br />GIOU[ inspecdon By p4ALiSLIP "d; l L, Date, �7( zy-- U JrCIrIHL YYCII r'ei ialii <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS I (? I fJSP(� i `eK 7 3-o P o ° D7dc'" ' Y <br />t0 '_ri ,er�P , A110�C ��P_f'/IMI O j o: !n 's. r;T 6� AI c " r / f' A ons C/rAie <br />N <br />m <br />m <br />D <br />0 <br />m <br />m <br />N <br />�Qij <br />or ��_ <br />J."+rCri,bi. <br />�c JV ndi.erv.ti a.11CL.1R! eaiii0iiiii Date relll°Y Invoice# well IDIN <br />Codes Info By- Cash Remitted Service Request# <br />3�aISO <br />fy s(, ' 3 d <br />.50 <br />li[IDM3-06 1025 2021 /�`�%r "✓L Gf� �$�' Pogo t ut'a j � � 7, � .� � tvott: Pump Permit <br />