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rnmcnall�c, bS�a Uaies,��>n (112s) 3\5-31ECEIVED <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209)9963-76697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS _ !3q-5 '/V <br />• n-((jr� DITy/zIp Manteca, CA 95337 2 9 2018 <br />CROSS STREET Swanson Road APN 19844.6-21 PARCEL SIZE • r41LD USE APPLICATION D <br />O <br />NAME City of Manteca PTMRO i� <br />(�,, (` ``�v PPHHONE <br />ADDRESS 10()� )NkA Cery\xk -}k ���_� � � ITV STATEZP \ aXVkP— _((/\,�](A <br />,CTOR BSK Associates i PHONE L - J`5 -JIS <br />,CTORADDRESS 399 Lindbergh Ave. CITYISTATE/ZIP Livermore, CA 94551 <br />SUBCONTRACTOR Exploration GeoServices Inc. <br />PHONE 408-483-9026 <br />SUBCONTRACTOR ADDRESS 1535 Industrial Ave. CITY/STATE/ZJP San Jose, CA 95112 <br />LICENSE X C-57 C-61 D-09 Other NUMBER 484288 EXPIRATION DATE 12/31/19 <br />DOMESTIC WELL SAMPLING: 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: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of bonngs X Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of bonngs <br />Drilling Method Mud Rotary Air Rotary X Auger Cahle Tool Push Point Other <br />Proposed Well Depth 40 ft Excavation 8 in diameter Open Bottom i Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thicknes /Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20' x ther Bore hole will be backfilled with cement grout using tremie methods <br />Grout Placement Method X Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />I 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 />INIMUM 48 HOUR ADVANC NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />n, A t TITLE Staff Engineer DATE 5/24/18 <br />See Attached Site Plan <br />PA MENTUS O Y <br />Application Accepted By / / Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS <br />TIN <br />Date <br />Area0ployee ID# <br />SPECIAL WeII Permit <br />WAIVER Received <br />Constructed Well Depth <br />EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />TA L, H EALT" <br />AIENT <br />FfY,EAiT <br />012018 <br />..//V C <br />-'NR At <br />