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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELToN AVENUE-STOCKTON CA 95205-(209)468-1420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDREss 1953 London Ave Crr2iP Manteca/95336 bis <br /> CRG%s STREET Komenich Or APN 202-290-33 PARCEL SIZE 1--- LAND USE APPLICATION t C <br /> A <br /> m <br /> OWNER NAME City of Manteca PHONE (209)456000 a <br /> OWNER ADDREss 1001 W Center St CITY/STATE/ZIP Manteca/CA/956337 <br /> CONTRACTOR Taber Drilling PHONE 1(916)371-6234 <br /> CONTRACTOR ADDRESS 536 Galveston St CmISTATErLP West Sacramento/CA/95691 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDREss CiTY/STATEMP <br /> LICENSE ®C-57 C C-01 C D-09 C Other NUMBER 969927 EXPIRATION DATE 07129/2020 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Ditxomochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ❑DomeshoPrivate D Inigetion/AgriaAtural D Industrial C Water Quality Monitoring 19 Soil Sampling/Characterization <br /> C Public Water System <br /> It df—M eom Own_ W.W Syatan N— Cant d N—w Phony N..b r <br /> TYPE OF WORK 0 New Wall n Replacement Well 0 Well A terstioNModi kation U Ottmer <br /> C Monitoring W§9(s) 8 of wells 0 Soil Bofing(s) "of WnP A Geotechnical 1 a or hormnes ��� <br /> D Oul-Mervice Well D 11Out-Of-Servioe Well Renewal Cross-Connection Repair <br /> C New Pump C Pump Replacement C Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION cc,A,,,-- 9 <br /> Drilling Method X Mud Rotary 0 Air Rotary D Auger O Cable Tool D Push Point D Other `�Y/V rr. IU//V 3 ij 19 <br /> Proposed Well Depth 50 R Excavation 6 in diameter 0 Open Bottom 0 Gravel PacluGravel SizeC <br /> C Conductor Casing in diameter / Conductor Casing Depth <br /> mneel R _— vILT•y'K NTq � <br /> Well Casing Dleter_In Thlckness/Gsuga/ASTM Schad 0 Sto Plastic D Stainless Steel 0 Othar PgRT <br /> Grout Sed Depth entire R 19 Nest Cement(94 lb bag/5-10 gal water) C Send Cement sack mrx17 grad water �F�T <br /> 0 Bentonite(20%solids) D Ottmer <br /> Grout Placement Method X Pumped D Free Felt C Other D Retardant/Accelerator(name) <br /> PEDESTAL Instilled By 0 Driller D Pump Contractor G Other <br /> 0 Concrete Pedestal CDlmenslons:Width R Length R Thick in 0 Christy Boz C Stove Pipe <br /> PttmP C Submersible[I Turbine C Other HP Pump Set R Standing Water Lavel R <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERSCOMPENSATi WS. <br /> M UR VANCE NOTICE REQUIRED FOR�IN/$P CONS-PLEASE CALL(209)953 697 <br /> SIGNED TITLE V i DATE <br /> FSP RTMENT U ENLY <br /> Application Accepted By Date CV Area Employee I11 <br /> h&16V <br /> Grout In3pection By Dale LI SPECIAL Well Pefftllt <br /> Pump Inspection By 9 Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE Sc Received ChocbW Amount Date PenTkW Invoice B Well IDtt <br /> Codes Info em Service R uest A <br /> (1 7 <br /> EHD 43-M—4.d 411VIO WELL/PUMP PERMIT <br />