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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> w <br /> JOB ADDRESS 1975 E Perrin RD&1500 E Perrin RD CITY/zIP Manteca/95337 m <br /> D <br /> CROSS STREET Perrin Rd APN 24109002&24109006 PARCEL SIZE 105.7 aC LAND USE APPLICATION# TEP Attached <br /> OWNER NAME Loren Haworth 91.06 ac PHONE (209)4794504 y <br /> OWNER ADDRESS 5496 West Ripon Road CITYISTATE21P Manteca,CA 95337 c40 <br /> Ut <br /> c�R/Consultant: AECOM Technical Services,Inc PHONE 916-679-2000 m <br /> ADDRESS 2020 L Street,Suite 400 CmISTATE/ZIP Sacramento/CA/95811 a_ <br /> 7 <br /> SUBCONTRACTOR Geo-EX Subsurface Exploration PHONE 916-799-8198 0 <br /> 9. <br /> SUBCONTRACTOR ADDRESS 1510 Madera Dr CITY/STATEMP Dixon/CA/95620 — <br /> CFO <br /> LICENSE x C-57 C-61 D-09 Other NUMBER 954267 EXPIRATION DATE 07/31/2020 0 <br /> T1 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) m <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring x Soil Sampling/Characterization <br /> Public Water System A <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> d <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of bonngs x Geotechnical 21 #of bonngs m <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair D <br /> New Pum Pum Replacement Pum Repair Raise Well Casingm <br /> WELL CONSTRUCTION Cn <br /> Drilling Method x Mud Rotary Air Rotary x Auger Cable Tool Push Point Other <br /> Proposed Well Depth 60-100 ft Excavation 8 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft x Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Sher Retardant/Accelerator(name) <br /> PEDes7AL 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9533-7Q6�9�7Q� <br /> SIGNED _ ITLE President DATE Iv1.L.sr� <br /> BE AtTikidim F DF. AOkIkN7- <br /> ED <br /> 1018 <br /> J <br /> N UN7y <br /> Tqj!�ATIL <br /> MENT <br /> PA TMENT US ONLY <br /> Application Accepted By Date 13 <br /> \ Area / ( Employee ID#/�~ <br /> P Y <br /> Grout Inspection B Date Swell Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By-,-:Ivry Date Constructed Well Depth ft <br /> COMMENTS �e1_ v ns . . irs Deaf <br /> PE Sc Received Check#/ Amount PermiU <br /> Codes Info BV Cash Remitted Date r\;ce Re uest# Invoice X Well ID# <br /> i <br /> �3 Zb <br /> EH043-06 revised4114/18 WELL/PUMP PERMIT <br />