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f <br />i WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />.��� r crtlnl I <br />JOB ADDRESS 18527 E SR -26 <br />CROSS STREET Duncan Road <br />I:ALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />APN 091-200-37 <br />OWNER NAME Linden Unified School District <br />OWNER ADDRESS 18527 E. Main Street <br />CITY/zIP Linden/ 95236 <br />EL SIZE 31.93 LAND USE APPLICATION # <br />PHONE 209.887.3894 <br />CITY/STATE/ZIP Linden, CA 95236 <br />CONTRACTOR V & W Drilling - Contact: Karli Stroing, President PHONE 209.981.7755 <br />CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATE/ZIP Galt, CA 95632 <br />SUBCONTRACTOR Condor Earth - Contact: Ron Skaggs, CA PE #44588/GE #2295 PHONE 209.601.1430 (Cell) <br />SUBCONTRACTOR ADDRESS 188 Frank West Circle, Suite I CITY/STATE/ZIP Stockton, CA 95206 <br />LICENSE C-57 I C-61 7 D-09 Other NUMBER720904 EXPIRATION DATE 04/30/2022 <br />IJVMt.1. I IL, rvtLL OAMPLING: u 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. <br />TYPE OF WORK ❑ New Well E Replacement Well <br />Water System Name <br />Ll Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings X Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump C Pump Replacement LJ Pump Repair C Raise Well Casino <br />Contact Name or Phone Number <br />2 # of borings <br />R � YMEI <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool Push Point C Other AD <br />Proposed Well Depth 10' to 25' ft Excavation 4 1/2 in diameter 11 Open Bottom Gravel Pack/Gravel Size In Ma4 <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft64 <br />Itt/ <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel ❑ Plastic Stainless Steel'exNOR QU/(� CO <br />Grout Seal Depth full depth ft X Neat Cement (94 Ib bag/5-10 gal water) C Sand Cement sac iEgrj <br />❑ Bentonite (20% solids) X Other Trernie <br />Grout Placement Method C Pumped ❑ Free Fall ❑ Other 7 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in C Christy Box C Stove Pipe <br />PUMP ❑ Submersible❑ Turbine C 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE. CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By r� 1 Date�d J <br />Grout Inspection By Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />N <br />-1 <br />M <br />D <br />0 <br />0 <br />M <br />M <br />rn <br />y <br />�T <br />D <br />Area CSI <br />% / Employee ID# F(,',, I1 /C .7 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit/ <br />Service Re uest # Invoice # <br />Well ID# <br />/ 104 In <br />/ Page 1 ort <br />Wcll / Punry Pcrmit <br />