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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 21908 South Manteca Road CITylZIp Manteca/95337 m D CROSS STREET Sedan Avenue 0.1 Miles Swbi of Site APN 226-120-13 PARCEL SIZE 4.88 LAND USE APPLICATION# o a m OWNER NAME Jag Singh PHONE OWNER ADDRESS 1463 Moffat Boulevard CITYISTATEIZIP Manteca/CA/95307 CONTRACTOR West Coast Exploration PHONE (209)985-7541 CONTRACTOR ADDRESS 1540 Roosevelt Avenue CITY/STATE2lp ESCALONICA/95320 SUBCONTRACTORICONSULTANT CTE CAL,INC. PHONE (209)543-1799 SUBCONTR ACTOR(CONSULTANT ADDRESS 4230 Kiernan Avenue,Suite 150 CITY/STATE/ZIP MODESTO/CA/95356 LICENSE m -57 0-61 D-09 ❑Other NUMBER 870761 EXPIRATION DATE 01/31/2020 BILLING PARTY: OWNER ❑CONTRACTOR k SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:ii General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)D Arsenic(4393) INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial Water Quality Monitoring ❑Soil Sampling/Characterization Public Water System If different from Omer. Water System Name Contact Name or Phone Number TYPE OF WORK New Well D Replacement Well - Well Afteration/Modification 7 Other Monitoring Well(s) #of wells Soil Boring(s) *ofbodngs Q Geotechnical aof borings Out-Of-Service Well Out-Of-Service Well Renewal ❑Cross-Connection Repair New Pump Pump Replacement _ Pump Repair ❑Raise Well Casing WELL CONSTRUCTION 'J Drilling Method Mud Ro ❑Air Rotary y quger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth ft Exca ation in diameter C Open Bottom ❑Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Schad D Steel ❑Plastic ❑Stainless Steel Other AyMF Grout Seal Depth ft at Cement(94 Ib bagl5-10 gal water) ❑Sand Cement sack mix17 gal water Bentonite(20%solids) ❑Other Grout Placement Method -Pumped _-.Free Fall ❑Other Retardant/Accelerator(name) A PEDESTAL Installed By Driller Pump Contractor Other VG Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box Stove Pipe 019 PUMP Submersible Turbine .Other HP Pump Set ft Standing Water Level ft JOAQ(f�N I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH -r�R�NA , �UNry CURRENT AND ACTIVE ZAQ JOAQUIN COUNTY (WITH THE SCAL CALIFORNIA CONTRACTORS STATE TATE LAWS, AND RULES AND ULICENSE BOARD AND LATIONS. I ALSO THAT 1 AM N COMPLIANCE TIFY THAT MY REQUIRED LICENSE ALL H�FPM NT WORKERS COMPENSATION LAWS. MINIMUM 48� QHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED lea4.9 1��/v TITLE Staff Geologist DATE 8/22/2019 S E E A T T A C H E D L 0 C A T 1 O N I M JA I P l?ARTMENT E O LY Application Accepted By Date AreXWA loyee ID# �I - Grout Inspection By Date ECIAL Well Per_It Pump Inspection By_ Date� IVER R.celVed Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#! Amount Permit! Date Invoice# Well ION Codes into Cash Remitted Service Re uest# dm EHD43-06 6/11/2019 �(�' �� WELL/PUMPPERMIT