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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 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 /> JOB ADDRESS 800 Moffat Blvd. CITY/ZIP Manteca, CA 95336 m <br /> CROSSSTREET S. Garfield Ave /Lp�,�t/22�1 4061 PARCEL SIZE ' 55 LAND USE APPLICATION# <br /> OWNERNAME /i��(l/�/� �P/HHO{NEE <br /> OWNER ADDRESS (-Ctrl CllL '4f CITYISTATE(LIP <br /> CONTRACTOR Kleinfelder PHONE 209.948.1345 <br /> CONTRACTOR ADDRESS 2001 Arch-Airport Road, Suite 100 CITYISTATEIZIP Stockton, CA 95206 <br /> SUBCONTRACTOR V&w Drilling, Inc. PHONE 209.469.7700 <br /> SUBCONTRACTOR ADDRESS 1133 Blackhurst Dr CITYISTATERIP Galt, CA 95632 <br /> LICENSE CY-C-57 D C-61 G D-09 D Other NUMBER 720904 EXPIRATION DATE 04/30/2020 <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)7 Dibromochloropropane(4392)-1 Arsenic(4393) <br /> INTENDED USE L DomesllclPfivale U Irrigation/Agricultural a Industrial U Water Quality Monitoring X Soil Sampling/Characterizalion <br /> F Public Water System <br /> Ifdlfferentfrom Owner: Water System Name Contact Name or Phorte Number <br /> TYPE OF WORK C Now Well 7 Replacement Well D Well AlterallonlModl8ca8on C Other <br /> E:Monitoring Well(s) #of wells D Soil Boring(s) If of borings R Geotechnical 1 8 of borings <br /> L Out-Of-Service Well LI Out-Of-Service Well Renewal U Cross-Connection Repair <br /> r New Pum f Pump Replacement r Pump Repair -1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r Mud Rotary n Air Rotary XAuger r Cable Tool n Push Point f- Other <br /> Proposed Well Depth 2 0 it Excavation 6 In diameter D Open Bottom D Gravel Pack/Gravel Size In diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched I I Steel I 1 Plastic I Stainless Steal I i Other <br /> Grout Seal Depth 2 0 ft X Neat Cement(94 1b bag15-10 gal water) n Sand Cement sa lr mixt7 gal water <br /> U Bentonite(20%solids) U Other <br /> Grout Placement Method n Pumped PRM' Other ri Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By U Driller U Pump Contractor a Other <br /> C Concrete Pedestal DDitnensions:Width it Length ft Thick in ]Christy Box D Stove Pipe <br /> PUMP C Submersible❑Turbine 7 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 /> I IMUM 48 FjQ R ADVANCE NOTICE REQUIRED FPR INSPECTIONS <br /> (-PLEASE CALL(209�)�9�5�3.7 97 <br /> PfSIGNED- 04( __._______ TITLE S c �"`1LU DATE L l 1 1 <br /> el) <br /> 2018 <br /> NrL <br /> CO <br /> RTUCNT <br /> A TMENT U E O Lx ���� <br /> Application Accepted By ale Area Employee ID# <br /> Groin Inspection By Dale ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ii [► _ Cl WAIVER Received <br /> SDI,Boring In �(ctlon B Date 1 1 it Constructed We Depth rift <br /> COMMENTS VSQi� Y�OYf 1/1S (?� rg./MAfL ✓1[ I(J[ntlf �l' <br /> PE SC Received Check#1 Amount Permltl <br /> Codes Info B cavil Remlited Date Se Ice Request# Invoice# Well ID# <br /> Z 5 <br /> EHD 4108-1-d4/14118 WELLIPUMP PERMIT <br />