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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95206-(209)468-1420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> Joe ADDRESS 480 Moffat Blvd Crnr/LP Manteca 195336 <br /> s <br /> CROSSSTREET_Garfield Avenue APN 221-040-61 PARCEL SIZE -%.jg2s LAtm USE APPLICAmoN/ o <br /> A <br /> m <br /> OWNER NAME _ City of Manteca PHONE (209)45641000 e <br /> OWNER ADDREss 1001 W.Center St. CITY/STATE/DP Manteca(CA/95337 <br /> CONTRACTOR Taber Drilling PHONE 1(916)371-8234 <br /> COWWCTOR ADDRESS 536 Galveston St CrtY/STATE173P West Sacrarnento/CA/95691 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDREas CRYISTATEMP <br /> LICENSE X C-57 0 C61 :1 D-09 ❑Other NUMBER 969927 EXpMTION DATE 02/29/202D <br /> DOMESTIC WELL SAMPUNQ:❑General Mineral/Coliform Bacteria(4391)rl Dibromochloropropene(4392)❑Arsenic(4393) <br /> INTENDED USE U DomesticfPnvete 0 Inigetion/Agricuttural ❑Industrial ❑Water Quality Monitoring K,Sol Sempling/Cheractenzatton <br /> 0 Public Water System <br /> tf dfforent frau O- Water 6yct«n Neme Catty lint a Ph—Kit.," PA` <br /> TYPE OF WORK ❑New Wel a Replacement Well 0 Wedi <br /> Wall Atteration/Mofication ❑Ottw <br /> 0 Monitoring Wel(*) a of wags n Sal Boring(s) s or I»ri- A Geotechnical 1 a o•b kq. <br /> ❑Out-Of-Service Wen ❑Out-Of-Service Well Renewal n Cross-Cwnectlon Repair <br /> Now Pump ❑Pump Replacement l]P Repair ❑Ralse Well Casing <br /> ^'I�R <br /> WELL CORSTt2UCTION <br /> Drilling Method 9 Mud Rotary 0 Air Rotary ❑Auger 0 Cable Too! 0 Push Pant Ci O9xr ✓� •/ �P <br /> Proposed Wen Depth 50 n Excavation 6 In diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in R�Ul y G,O <br /> U Conductor Casing in diameter / Conductor Casing Depth it u <br /> Wet!Casing Diameter_In ThIciams/Geuge/ASTM Schad 0eel Stu Plastic 0 Stainless Steel 0 Other ry ZQV� )-ANry <br /> si <br /> Grout Seal Depth entire It X Neat Cement(94 Ib bag1rf D gal water) 0 Sand Cement sack mid7 gal Weiler MFNr <br /> ❑Bentonite(20%colds) ❑Other <br /> Grout Placement Method X Pumped 7 Free Fel Cl Other ❑Retardant/Accelerator(nerna) <br /> PEDE*JAL Wstatled By 0 Diller 0 Pune Contractor L, Other <br /> 7 Concrete Pedestal ODimenslam:Vk4dth R Lernglh ft Thick in 0 Christy Box ❑Stove Pipe <br /> MP 0 SubmersiMeo Turbine 0 Other HP Pump Set n Standing Water Leve R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED TFtlS 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 WFTH ALL <br /> WORKERS COMPEN lAWS. <br /> U S HOUR !t TICE REQUIRED FOR INSP CTIONS-PLEASE CALL(209)9 - 697 <br /> SHINED DATE Q 1,r{ <br /> f-R MENT UgE ZO <br /> Application Accepted Byz��'�� &.N4d�te Artie r��C"'� F_rrtployee IDRF/������ <br /> Grout Inspection By Date ❑ SPECIAL W811 POrmit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date V/ I// ►,/ Constructed Well Depth tt <br /> COMMENTS <br /> PE Sc Received C Amount Date PermW Invoice k WallID9 <br /> Codes Info Cash Remitted Service Requead0 <br /> = (L <br /> EHO 43-W revised VIVto WELL rPUMP PERMIT <br />