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�4 be q �' <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 /> f/1 <br /> JOB ADDRESS Hwy 99 CITy21P Manteca 95337 <br /> D <br /> CROSS STREET Austin Rd APN NA PARCEL SIZE NA LAND USE APPLICATION# a <br /> m <br /> OWNER NAME Caltrans PHONE �H <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR Blackburn Consulting PHONE (916)375-8706 <br /> CONTRACTOR ADDRESS 2491 Boatman Avenue CITY/STATEZP West Sacramento,CA,95691 <br /> SUBCONTRACTOR Taber Drilling PHONE (916)371-8234 <br /> SUBCONTRACTOR ADDRESS 536 Galveston St CITY/STATEZP West Sacramento,CA,95691 <br /> LICENSE ix C-57 ❑C-61 ❑D-09 0 Other NUMBER 969927 EXPIRATION DATE 02/29/2020 <br /> DOMESTIC WELL SAMPLING:L7 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑DomesticJPrivate Ci Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring N Soil Sampling/Characterization <br /> 1-1 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 9 Soil Boring(S) #of borings N Geotechnical 10 #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement 0 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method x Mud Rotary 0 Air Rotary N Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 5 to 80 ft Excavation 4 to 6 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth entire it 2 Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ®Pumped _ Free Fall .Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set it 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 /> �UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PL S CA�(209)953-7697 <br /> SIGNED TITLE VP/Exploration Coordinator ATE 02.06.2019 <br /> 1 <br /> E/VE® <br /> 012019 <br /> a"9 IV 0 <br /> y NMFOTY <br /> N7A� <br /> pARTIM,FNT <br /> D P TMENT USE NLYb /�' <br /> Zoll Area / -/ Employee ID# �� <br /> Application Accepted By Date <br /> Grout Inspection Bytz/r Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />