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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />IYUIY-Rtt UNUAt3LL I-LKMI l S.ALL (LUV) U*J-7bV 7 FOR INSPECTIONS hAF'IKtS 7 YEAR FROM DATE ISSUEC <br />JOB ADDRESS +3 E. Southland Road c,TY/z,P Manteca, CA 95336 <br />CROSS STREET W. of Cottage APN 218-130-04 PARCEL SIZEA5LAND USE APPLICATION # <br />OWNER NAME TH Shadowbrook Investor's LLC PHONE 925-999-3950 <br />OWNER ADDRESS 3001 Bishop Dr., Ste. 100 CITYISTATE/ZIP San Ramon, CA 94583 <br />CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 545-118.5; <br />CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto, CA 95356 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 i C-61 i D-09 f_ <br />CITY/STATE/Z,P. <br />NUMBER 290813 <br />EXPIRATIONDATE 5-31-18 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE i- Domestic/Private iXlrrigation/Agricuhural IJ Industrial J Water Quality Monitoring IJ Sail Sampling/Characterization <br />I j Public Water System <br />If different from Owner: a er <br />Ty <br />em ama on a ame or one um r <br />TYPE OF WORK XNeW Well I_. Replacement Well I_ Well Alteration/Modification J Other <br />I Monitoring Well(s) # of wells F Soil Boring(s) # or borings J Geotechnical # of borings <br />i-- Out -Of -Service Well I. Out -Of -Service Well Renewal r Cross -Connection Repair <br />i New Pump Pump Replacement i Pump Repair i Raise Well Casino <br />Drilling Method [XMud Rotary J Air Rotary I Auger I Cable Tool '. Push Point 1 j Other <br />Proposed Well Depth 200 ft Excavation _2_ in diameter i Open Bottom XGravel Pack/Gravel Size No. 6 in diameter <br />-I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ 2 in Thickness/Gauge/ASTM Sched SDR21 i I Steel XPlastic i- Stainless Steel [_ Other <br />Grout Seal Depth 50 ft I Neat Cement (94 Ib bag/5-10 gal water) XSand Cement 10.3 sack mixf7 gal water <br />I_I Bentonite (20% solids) i I Other <br />Grout Placement Method !XPumped i Free Fall i Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By i DrillerPump Contractor I I Other <br />i Concrete Pedestal Dimensions: Width it Length ft Thick in i i Christy Box i Stove Pipe <br />PUMP Submersiblei7 Turbine r Other HP Pump Set ft Standing Water Level ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NQTICF. REQUIRED FOR INSPECTIONS <br />SIGNED .10 I E Vice President DATE Mar. 1. 2018 <br />Application Accepted By <br />DEPTMENT U E Y <br />` Date <br />Area Employee ID# <br />Grout Inspection By <br />Date <br />SPECIAL Well Permit <br />Pump Inspection By <br />Date <br />WAIVER Received <br />Soil Boring Igspection By <br />Date <br />Constructed Well Depth <br />Qa ft <br />rn <br />D <br />0 <br />M <br />w <br />N <br />PE SC Received a <br />Codes Info B s <br />Amount Date Permit/Invoice # Well ID# <br />Remitted Service Re uest # <br />SLG--5/1"'IjeT <br />n <br />EHD 43-08 <br />8/04100 <br />WELL /PUMP PERMIT <br />