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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENWRONMENTAL HEALTH DEPARTMENT 1s6s EAST HAZELTON AVENUE-STOCKTON CA 95205•(209)463414H <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> w <br /> Jos ADDRESs 1739 E Atherton Or CITy/Lp Manteca 195337 <br /> D <br /> CRO33 STREET Woodward Ave APN 224-47043 PARCEL SIZE 0.88 erm LAND 116E APKjcATON>R <br /> OWNER NAME City of Manteca PHONE (209)456-8000 <br /> OWNER ADDRESS 1_001 W Center St CtTY/STATEMP Manteca f CA/95337 <br /> CONTRACTOR Taber Drilling PHONE 1(916)371-8234 <br /> CoNTRACToR ADDRESS 536 Galveston St CITYISTATE/LP. West Sacramento/CA/95691 <br /> SUBCONTRACTOR PHONE <br /> SuacoNTRACTOR ADDResa CITY/STATE/IlP <br /> LICENSE X C-57 C C-61 =D-09 C Other NuMRER 969927 EXPIRATION DATE 02/292020 <br /> DoMESTtc WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)D Dibronwchloropropene(4392)11 Arsenic(4393) <br /> INTENDED UsE C Domestic/Private ❑Irrigation/AgriaAlural ❑Industrial ❑Water Quality Monitoring it Sou Sampling/Characterization <br /> 0 Pubic Water System <br /> It die.ent Fan Owner. Wer.8yshm Nemo Gamed Nemo a Phone Numb. <br /> TYPE OF WORK 7 New Wes D Replacement Wed D Wel ARarationlModification ❑Other <br /> 0 Monitoring Wel(s) ROf Weis ❑Sol Boring($) Sorb1v'0` X Geotechnical 4 0o borbps <br /> PA <br /> C Out-OTServioe Well C Out-Of-Service Weil Renewal 0 Cross-Connection Repair <br /> C New Pump 0 Pu Replacement C Pump Repair ❑Raise Wel Casingv <br /> WELL COMMUC 1ON ,,ryry <br /> Drilling Method to Mud Rotary D Air Rotary R Auger ❑Cable Tool 0 Push Point ❑ Other <br /> Proposed Wag Depth 50.15.5.5 ft Excavation 6.4.4.4 in diameter ❑Open Bottom ❑Gravel Paci/Gravel Size In dia ` 2019 <br /> 0 Conductor Casing In diameter / Conductor Casing Depth ft E 0AQU/)y <br /> Well Casing Diameter_In Thidmess/Geuge/ASTM Schell ❑Steel ❑Plastic D Stainless Steel D Other <br /> Ro mM ^Qr�N� <br /> Grout Seal Depth enure ft A Neat Cement(94 Ib bag�TO gal wafer) ❑Sand Cement sack mix/7 pal <br /> 0 Bentonite(20%Bolds) ❑Outer ARTjyr�N <br /> Grout Placement Method x Pumped a Free FSI ❑Other 0 Retardant/Accelerator(name) T <br /> PEDESTAL Installed By C Driller D Pump Contractor D Ottw <br /> C Concreb Pedestal LlDimenslons:Widthft Length ft 7bk k In a Christy Box ❑Stave Pipe <br /> IE--p 0 Submersible❑Turbine D Other HP Pump Set It Standing Water Level ft <br /> 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE LAWS. <br /> U HOU CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9!61-7697 <br /> SIGNED s TTTtt �r ' DATE L <br /> LA <br /> PA MENT pft O LY <br /> Application Accepted Bya Area vEmployes[DO <br /> Grout Inspection By Date 0 SPECIAL W@II Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection ByDate Constructed Well Depth ft / <br /> COMMENTS -l ) <br /> PE SC Received AmountDatePenult/ Invoke s Well ION <br /> Codes Info B Remitted Servlee R R <br /> EHD 43-M rinsed 4/14118 WELL/PUMP PERMIT <br />