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WELLIPUMP 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 /> JOB ADDRESS 1739 Atherton Drive. clrt¢lP Manteca, CA 95336 ( <br /> CROSS STREET Tesoro Drive APN 22447043 PARCEL SIZE Q• 66 LAND USE APPLICATION# <br /> OWNERNAME ' /� PHONE �) y <br /> OWNER ADDRESS r�d 14/ CITYISTATEIZIP <br /> CONTRACTOR Klein elder PHONE 2`09.948.1345 1- <br /> CONTRACTOR ADDRESS 2001 Arch-Airport Road, Suite 100 CITY1STATEMP Stockton, CA 95206 <br /> SUBCONTRACTOR V&W Drilling, Inc. PHONE 209.469.7700 <br /> SUBCONTRACTORADDREss 1133 Blackhurst Dr CrrY1STATEIZIP Galt, CA 95632 . <br /> LICENSE OCC-57 ❑C$1 ❑D-09 ❑Ofher NUMBER 720904 EXPIRATION DATE 04/30/2020 <br /> DOMESTIC WELL SAMPLING.❑General Mineral/Caliform Bacteria(4391)3 Dibromochloropropane(4392)3 Arsenic(4393) <br /> INTENDED USE L DomesticlPtivale u Irrigalion/Agriculturai u industrial u Water Quality Monitoring %Soil Sampling/Characterization <br /> r-Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Wail 7 Replacement Well ❑Well AlteratlonlModification ❑Other <br /> C Monitoring Wells) #of wells ❑So6 6oring(s) #of borings Ix Geolechnical 1 A of bodngs <br /> L Out-Of-Service Well u Out-Of-Service Well Renewal U Cross-Connection Repair <br /> F New Pum rl Pump Replacement F Pump Repair -1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r Mud Rotary n Air Rotary rid Auger r Cable Tool Il Push Point F Other <br /> Proposed Well Depth 20 It Excavation 6 In diameter ❑Open Bottom ❑Gravel Pack/Gravel Size In diameter <br /> ❑Conductor Casing In diameter / Conductor Casing Depth ft <br /> Wall Casing Diameter_In Thickness/Gauge/ASTM Schad i I Steel I I Plastic i Stainless Steel I i Other <br /> Grout Seal Depth 2 0 ft X Neat Cement(941b boo-10 gal water) n Sand Cement sack mix/7 gal water <br /> LI Bentonite(20%salads) u Other <br /> Grout Placement Method nPumped-Afkel all Vbther ,g&RAIS n Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By U Driller u Pump Contractor u Other <br /> C Concrete Pedestal❑Dimenslons:Width it Length R Thick In 3 Christy Box ❑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 /> VI IMUM 48 Hp A VANCE NOTICE REQUIRED FOR INSPECT NNS/-PLEASE CALL(2091)9 3-76 7 <br /> SIGNED ! _C11A TITLE l ]I, l5 V-U IJL. �lt- DATE V <br /> 19 1 <br /> q�Y��NT <br /> �I VED <br /> 2 ?018 <br /> - H E A "MNT ry <br /> EN <br /> PAR MENT ZU E�N�Y <br /> hyll <br /> ApplIcallon Accepted By ' to Area Employee 04,4zi <br /> Grout Inspection By Date OOSLPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring In (�e�cII,Q(L1n By Date 4 � Construct d Weil a th ft <br /> COMMENTS �1CV (�f`Ayr I h5 �✓ K/M11� NO )/✓t1e✓ — <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service <br /> Re uest# <br /> EHO 43-O6 revised 4114118 ���� ��� WELL IPUI,IP PERMIT <br />