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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 /> JOB ADDRESS 450E.Yosemite AvenueQ t! � CITY/ZIP Manteca/95336 m <br /> 2 s <br /> CROSS STREET So.Garfield Avenue qpN �D ��� PARCEL SIZE I•� LAND USE APPLICATION# o <br /> A <br /> m <br /> OWNER NAME Manteca Unified School District-Contact:Jeff McLarty,Constr./Energy Tech. PHONE 209.858.0758 ai <br /> OWNER ADDRESS 2271 W.Louise Avenue CITY/STATE¢IP Manteca,CA 95337 <br /> CONTRACTOR V&W Drilling-Contact:Karli Stroing PHONECell:209.981.7755 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive Cm/STATE/ZIP Galt,CA 95632 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIN/STATE/ZIP <br /> LICENSE X C-57 ❑C-61 0-09 ❑Other NUMBER 720904 EXPIRATION DATE 04/30/2020 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑Dibrorrochloropropane(4392)r Arsenic(4393) <br /> INTENDED USE rEj Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK a New Well ❑Replacement Well ❑Well Afteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells C Soil Boring(s) n of borings X Geotechnical 5 If of borings <br /> i7 Out-Of-Service Well G Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point 7 Other <br /> Proposed Well Depth Ill ft Excavation 4.5 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 Fi Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth full depth ft Nif Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method D Pumped ❑Free Fall X Other Tremie Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑Pump Contractor a Other <br /> n Concrete Pedestal❑Dimensions:Width ft Length ft Thick in U Christy Box D Stove Pipe <br /> PUMP Submersible Turbine F'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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND AC VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO�ATIONAWS. <br /> MINIAD CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLEVice President,Engineering Services DATE 03/18/19 <br /> YMENT <br /> CEIVED <br /> SO- <br /> 19 2019 <br /> AQUIN COUNTY <br /> RONMENTAL <br /> DEPARTMENT <br /> Z.A TMENT UAE NLY <br /> Application Accepted By O Date Area mployee ID#/ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By M 44 1Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/Codes Info Cash emitted Date Service Re uest# Invoice# Well ID# <br /> de <br /> I <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />