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1 <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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> M)JOB ADDRESS Austin Rd CITY/ZIP Manteca 95337 m <br /> D <br /> CROSS STREET Moffat Blvd APN NA PARCEL SIZE LAND USE APPLICATION# A <br /> m <br /> OWNER NAME City of Manteca PHONE m <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR Blackburn Consulting PHONE (916)375-8706 <br /> CONTRACTOR ADDRESS 2491 Boatman Avenue CITY/STATE/ZIP West Sacramento,CA,95691 <br /> SUBCONTRACTOR Taber Drilling PHONE (916)371-8234 <br /> SUBCONTRACTOR ADDRESS 536 Galveston St CITY/STATE/ZIP West Sacramento,CA,95691 <br /> LICENSE x C-57 C-61 D-09 J Other NUMBER 969927 EXPIRATION DATE 02/29/2020 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)- Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED U Domestic/Pdvate Irrigation/Agricultural !Industrial -Water Quality Monitoring x Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well -Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells x Soil Borings) #of borings x Geotechnical 7 #of borings <br /> i Out-Of-Service Well I Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pum i Pump Replacement L Pump Repair i-Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Lx Mud Rotary -Air Rotary x Auger i Cable Tool i Push Point I Other <br /> Proposed Well Depth 5 to 80 ft Excavation 4 to 6 in diameter i Open Bottom i I Gravel Pack/Gravel Size in diameter <br /> i_I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel I Plastic I i Stainless Steel I I Other <br /> Grout Seal Depth entire ft x Neat Cement(94/b bag/5-10 gal water) i Sand Cement sack mix,7 gal water <br /> 17 Bentonite(20%solids) I1 Other <br /> Grout Placement Method ❑Pumped I1 Free Fall i Other -1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor - Other <br /> Concrete Pedestal-Dimensions:Width ft Length ft Thick in C Christy Box -Stove Pipe <br /> PUMP :_Submersible:-i 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 /> 4 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE C LL(209)953-7697 <br /> SIGNED TITLE VP/Exploration Coordinator DATE 02.06.2019 <br /> R 0 , 2019 <br /> Q(1/ly coVrRCuN7Y <br /> EPgR AL <br /> SENT <br /> _D Ep A R T M E N�U S ONLY <br /> Area XIA <br /> Application Accepted By (�/}/ Date / <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Sail Boring Inspection By /y Date-� // /� Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received heck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Request# <br /> le <br /> EHO 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />