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r w <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 /> 0)Joe ADDRESS 225 Swanson Road CmManteca/CA/95337 <br /> a <br /> CROSS STREET APN 198-17-037 PARCELSIZEtL!4_LAND USE APPLICATION# z <br /> m <br /> OWNER NAME Sunnyvalley Smoked Meats,Inc. PHONE 209-825-0288 <br /> OWNER ADDRESS 2475 West Yosemite Avenue CITY/STATE/ZIP Manteca/CA/95337 <br /> CONTRACTOR Geo-Ex Subsurface Exploration PHONE 916-799-8198 <br /> CONTRACTOR ADDRESS 1510 Madera Drive cITY/sTATEmP Dixon/CA/95620 <br /> SUBCONTRACTOR Crawford&Associates,Inc. PHONE 209-312-7668 <br /> SUBCONTRACTOR ADDRESS 1165 Scenic Drive CITY/STATEIZIP Modesto/CA/95350 <br /> LICENSE V C-57 ❑G-61 CI D-09 0 Other NUMBER 954267 EXPIRATION DATE 7/31/2020 <br /> DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)7 Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring R Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ,-1 New Well r Replacement Well -i Well Alteration/Modification I1 Other <br /> ❑.Monitoring Wells) #of wells ❑Soil Boring(S) #of borings x Geotechnical 2 #of borings <br /> IL Out-Of-Service Well a Out-Of-Service Well Renewal L Cross-Connection Repair <br /> D New Pump L Pump Replacement ❑Pump Repair !I Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method L,Mud Rotary ❑Air Rotary x Auger a Cable Tool Push Point a Other <br /> Proposed Well Depth 15 to 30 ft Excavation 6 to 8e in diameter Open Bottom L Gravel Pack/Gravel Size in diameter <br /> Li Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel n Plastic r�Stainless Steel i�Other <br /> Grout Seal Depth full depth ft X1 Neat Cement(94 Ib bag/5-10 gal water) n Sand Cement sack mix/7 gal water <br /> 11 Bentonite(20%solids) r Other <br /> Grout Placement Method ❑Pumped C Free Fall k Other Tremmie ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller -1 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal 71 Dimensions:Width ft Length ft Thick in G Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible Turbine �1 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 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Tom Scott TITLE President DATE 1-16-19 <br /> ENT <br /> IVED <br /> 6 2019 <br /> S J AQUIN COUNTY <br /> N I O MENTAL <br /> FF <br /> L PARTMENT <br /> E ARTMENT USE ONLY C-lkryJ <br /> Application Accepted B ate-1�� ` '--`� Are 04�trcCO-Employee ID# /v CtSSXNt <br /> Grout Inspection Date i SPECIAL Well Permit <br /> Pump Inspection By Date I y WAIVER Received <br /> Soil Boring Inspection By-P LKjnjTl411 k� Date l Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Cordes Info B Remitted Service Re uest# <br /> 7� ;� <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />