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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AvENUE-STOCKTON CA 95205-(209)4883420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS Defense Depot San Joaquin Sharpe CtrYZP Manteca,CA 95336 <br /> East of Almond St and South of Roth Rd ,'1 s <br /> CROSS STREET APN -0Z"j PARCELSIZE / - LAND USE APPLICATION o <br /> p <br /> OWNER NAME California Military DepartmentCLAffgp R,P PHONE <br /> OWNER ADDRESS 9800 Geothe-BOX 12 CmISTATE/DP Sacramento,CA,95826 <br /> CONTRACTOR Taber Drilling PHONE 916 3718234 <br /> CONTRACTOR ADoRESs 536 Galveston St. CfTI/STATEIZ P West Sacramento,CA 95691 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDREss CITYISTATEIIJP <br /> LICENSE to C-57 C G-61 11 D-09 a Other NUMBER 969927 EXPIRATION DATE 02/29/2020 <br /> DoMEsTtc WELL SAMPLING:o General Mineral/Coliform Bacteria(4391)o Dibromochloropropene(4392)G Arsenic(4393) ppmmP <br /> INTENDED USE i DomestlGPrivete o Irrigation/Agricuttural C Industrial E Water Quality Monitoring X Sal Sampling/Characterization ®pr�� �N? <br /> Public Water System ""�� �'�P®/ <br /> It dblic ate Owner. Water System Name Conrad Name or Phone Number `� <br /> TYPE OF WORK C New Well -i Replacement Well Well Alteration/Modikation U Other OR <br /> i. Monitoring Wefl(s) #of wells C Soil Bodng(s) s or nonny' g Geotechnical 1 #or borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal C Cross-Connection Repair ,f�A ?0e9 <br /> New Pum C Pum Replacement :7 P Repair G Raise Well Cast E QV//y <br /> WELL CONSTRUCTION IRAN C��N <br /> At <br /> Drilling Method C Mud Rotary C Air Rotary al Auger G Cable Tool "I Push Point _: Other N�EpgRTT'gG r r <br /> Proposed Well Depth 50 It Excavation 8 in diameter o Open Bottom n Gravel Pack/Gravel Size in diameter MENTI <br /> ❑Conductor Casing In diameter I Conductor Casing Depth It <br /> Wall Casing Diameter_in ThidmeWGauge/ASTM Schad C Steel C Plastic o Stainless Steel G Other <br /> Grout Seal Depth 50 R A Neat Cement(94 ID bag/5-10 gal water) ❑Sand Cement sack mixA gal water <br /> C Bentonite(20%solids) n Other <br /> Grout Placement Method 2 Pumped o Free Fab j Other G Retardant/Accelerator(name) <br /> PIEKSTAL Installed By ❑Driller i Pump Contractor C Other <br /> O Concrete Pedestal oDlmensions:Width it Length R Thick in Christy Box o Stove Pipe <br /> PUMP C Submersibleo Turbine o Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IN UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSSPECTIQNS/-PLEASE CALL(209)!953-7697 <br /> !S)iw <br /> SIGNED TITLE VT it- DATE <br /> A MENTI UpiE ONLY ��//���7y�� <br /> Application Accepted By mate Area��l�/�`� Elhpbyee ID4 � <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection ByDate WAIVER Received <br /> Y, <br /> Soil Boring Inspection By � Date r^t/ L J/!r{ Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount PermPermit/ # <br /> Codes Info B pate ash Remitted Sery ce Re uest# Invoice Well ID# <br /> END-01-06 rev!sed 4n4na ��/� D�/ �(C/�� WELL I➢UMP PERMn <br />