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Qj <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN <br />CALL (ZU9) 953-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS PdlsbM Road S a 11 <br />Crry/ZIP Manteca / 95337 <br />� <br />CROSS STREET E. Woodward Avenue APN #�#9�r3- PARCEL SI acre LAND USE APPLICATION # <br />OWNER NAMEAlbert Boyce dba Pillsbury Road Partner C I Woi�tlU'/'1��PHo <br />OWNER ADDRESS 120 Manteca Avenue -/2.7-5:6 Cj 91. ro ea DN%ls TA� Manteca, CA '%533 <br />CONTRACTOR West Coast Exploration PHONE 209.838.1723 <br />CONTRACTOR ADDRESS P.O. BOX 133 CITY/STATE/ZIP EScalon CA 95320 <br />SUBCONTRACTOR PHONE <br />CTOR ADDRESS <br />X C-57 <br />C-61 D-09 Other, <br />CITY/STATE/ZIP <br />NUMBER C-57-870761 EXPIRATION DATE 0 1 /31/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring )(Soil Sampling/Characterization <br />Public Water System <br />If different from Owner:Water SyStehl Name Contact Name or Phone NUMber <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bodng(s) "borings borings X Geotechnical 8 u of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 20 ft Excavation 4 1/2 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic I Stainless Steel Other <br />Grout Seal Depth ft X Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mW7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped XFree Fall Other 1 Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft 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 CDIP5NSATION LAWS. <br />MIN M �4�H Ij #bVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 'IrJ,!`�' zPE, GE #2295 TITLE Vice President DATE 11/13/17 <br />F'A�C NT <br />IcOVE p <br />4 ?01I <br />�ONM BOUNTY <br />�EpAR MENT <br />)E:A;TMENT USE ONLY <br />Application Accepted By Date (I' y ' �� Area S ftl r\ Employee ID# <br />'2A I Anm�/�" <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By�5111 Dater- WAIVER Received <br />Soil Boring Inspection By %�� /� . Date _Constructed Well Depth / ft <br />PE <br />Codes <br />SC Received <br />Info B <br />11"ChacW <br />ash <br />Amount <br />Remitted <br />D to <br />PermiU Invoice# WeIIID# <br />Service Request # <br />p <br />/-2 <br />y. <br />tHU 43-Ub WELL /PUMP PERMIT <br />4/30/12 <br />