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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 250 Commerce Avenue CITY/ZIP Manteca w <br /> m <br /> 1 D <br /> CROSS STREET Phoenix Drive APN PARCEL SIZE Z'SI LAND USE APPLICATION# o <br /> A <br /> OWNER NAME Home Depot an KellerHQNE 770-433-8211 Ext.81362 w <br /> OWNER ADDRESS 2455 Paces Ferry Road L CITY/STATE21PAtlanta,Georgia 30339-4024 <br /> CONTRACTOR Moore Twining Associates,Inc. PHONE 559-978-9535 <br /> CONTRACTOR ADDRESS 2527 Fresno Street CITY/STATE/ZIP Fresno,CA 93257 <br /> SUBCONTRACTOR/CONSULTANT Moore Twining Associates,Inc. PHONE 559-978-9535 <br /> SUBCONTRACTOR/CONSULTANTADDRESS 2527 Fresno Street CITY/STATE21P Fresno,CA 93721 <br /> LICENSE XC-57 -1 C-61 n D-09 n OtherNUMBER 506159 EXPIRATION DATE 2-28-21 <br /> BILLING PARTY: D OWNER XCONTRACTOR XSUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE D Domestic/Private n Irrigation/Agricultural C Industrial ❑Water Quality Monitoring X Soil Sampling/Charactenzation <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i I New Well I I Replacement Well I I Well Alteration/Modification i Other <br /> F1 Monitoring Well(s) III of wells nSoil Boring(s) #of borings XGeotechnical 2 #of borings <br /> Li Out-Of-Service Well a Out-Of-Service Well Renewal i Cross-Connection Repair <br /> D New Pump C Pump Replacement D Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary D Air Rotary JCAuger 7 Cable Tool n Push Point D Other <br /> Proposed Well Depth 25 ft Excavation 7" in diameter C Open Bottom D Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In Thicknes Gauge/ASTM Schad C Steel ❑Plastic D Stainless Steel C Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br /> F,Bentonite(20%solids) [- Other <br /> Grout Placement Method X Pumped X- Free Fall Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor n Other <br /> D Concrete Pedestal❑Dimensions:Width ft Length ft Thick In C Christy Box D Stove Pipe <br /> PUMP D Submersible(]Turbine C Other _ HP Pump Set ft Standing Water Level ft <br /> I 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. 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 /> Mlfjl{MUA�DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)C9�53-7697 <br /> SIGNED �61� / TITLE�lA�C�d- \"d-Y`aY2�l� DATE <br /> R qyM <br /> ,s FcF��NT <br /> Fp�� Fp <br /> ✓Ro��N ?�19 <br /> h pF qR�T�N�Y <br /> MFN� <br /> TMENT U EE N L Y <br /> Application Accepted By ate r Are Employee ID# K <br /> Grout Inspection By Date L� SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By MOMj — Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check Amount ate Permit/ Invoice# Well ID <br /> Codes Info B Re itted '21Service Request# <br /> END 43-06 6/11/2019 WELL/PUMP PERMIT <br />