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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 20329 Airport Way CITY/ZIP Manteca, CA 95337 <br /> m <br /> D <br /> CROSSSTREET Woodward Avenue APN 241-320-180-000 PARCELSIZE 157 LAND USE APPLICATION# o <br /> A <br /> OWNER NAME Joanne Kimbrough PHONE y <br /> OWNERADDRESS P.O. Box 809 CITU/STATE/ZJP Ripon, CA 95366 <br /> CONTRACTOR PHONE"5-c�1 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP rZ <br /> SUBCONTRACTOR West Coast Exploration Inc. PHONE 209-985-7541 <br /> SUBCONTRACTOR ADDRESS P.O. Box 133 CITY/STATE9Jp Escalon, CA 95320 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 01-31-2020 <br /> DoMESnC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring D Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well Replacement Well Well Alteration/Modification D Other <br /> ❑Monitoring Wells) #of wells i Soil Boringtt ofbodngs 0 of borings <br /> s) x Geotechnical <br /> DOut-Of-Service Well : Out-Of-Service Well Renewal D Cross-Connection Repair �,V <br /> D New Pump 13 Pump Replacement Pump Repair D Raise Well Casing <br /> ^� T <br /> WELL CONSTRUCTION (� ,'s;Z <br /> Drilling Method 7 Mud Rotary D Air Rotary Y Auger Cable Tool Push Point Other <br /> Proposed Well Depth 10-40 ft Excavation 5 in diameter D Open Bottom Gravel Pack/Gravel Size in dia t ?2 <br /> D Conductor Casing in diameter / Conductor Casing Depth ft $, y 2019 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched D Steel 'I Plastic Stainless Steel Other `�� ON <br /> Grout Seal Depth 10-40 ft X Neal Cement(94 Ib bag/5-10 gal water) D Sand Cement sack�'"�4� MF O(/N� <br /> Bentonite(20%solids) Other ti ARTTAt <br /> Grout Placement Method Pumped X Free Fall Other Retardant/Accelerator(name) MF�r <br /> PEDESTAL Installed By Driller D Pump Contractor Other <br /> D Concrete Pedestal'-i Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP D Submersible Turbine D 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. 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED //j—----- TITLE Owner/Operator DATE 4/15/19 <br /> =ate <br /> ENT USE O Y / <br /> Application Accepted By Area Employee ID#je!jj6/`� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By f UIWhJ f t L Date IC/7 ` Constructed Well Depth ft <br /> COMMENTS 'r/ rfila-tel).i a�it` <br /> PE SC Received hetc Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By_ ash Remitted Service Re ues-tt# <br /> EHD 43-05 revised 4/14118 WELL/PUMP PERMIT <br />