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WELLIPUMP 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 /> r Manteca.CA y <br /> JOB ADDRESS 5298 Brunswick Road CITYZP T <br /> CROSS STREET 99 Frontage APN Q I V OS J PARCEL SIZE If:LAN.USE APPLICATION R A <br /> OWNER NAME San Joaquin Delta Community College PHONE 209-954-5151 N <br /> OWNER ADDRESS 5151 Pacific Avenue CITYISTATEILP Stockton,CA 95207 <br /> CONTRACTOR "' �ASCOfialc� IrPHONE <br /> CONTRACTOR ADDRESS "1'i W Dakota AvnjU i Cirv/STATE/LP 1O1'" :'-imia 93612 <br /> SUBCONTRACTOR ta.-an d ASsociales,Inc. PHONE 559.346 2200 <br /> SUBCONTRACTOR ADDRESS CITY/STATEILP -i"�'' 1-aiirnrnia X3512 <br /> LICENSE VC-57 C-61 D-09 Other NUMBER 449908 EXPIRATION DATE !'I 3t." <br /> DOMESTIC WELL SAMPLING: General Mineral/Coldorm Bacteria(4391) 1 Dibromochloroproperle(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Imgabon/Agncultwal Industrial I I Water Ounlily Monitorklg Soil SamplmglCharectenrahon <br /> Public Water System <br /> If r 11e of kora Owner U*.W,Sy51Prn Nemo Contact Nath or Phoria Number <br /> TYPE Of:WORK New Well Replacement Well Well Alteration/Modificalion Other <br /> Monitoring Welles) M of wells Sod Bonngls) A-d r,nnim` ✓Geotechnical 12 x of\"Ono` <br /> Out-01-Service Well Out-01-Service Well Renewal Cross-Connection Repair (10.50 Feet) <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary .f Auger Cable Tool Push Pam Other <br /> Proposed Well Depth IT Excavation in diameter Open Bottom Gravel Pack/Gravel Size In diameter <br /> Conductor Casing in diameter / Conductor Casing Depth_fl <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft ./Neat Cement(N4 Ib Dag/5-10 gat water) Sand Cement sack mix/7 gal water <br /> Bentonde(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Dnller Pump Contractor Other <br /> Concrete Pedestal Dimensions VMdth_h Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set h Standing Water Level fl <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 /> M 48 HOU ANC TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> ht..n vpnO fnyitu 0310812019 <br /> SIGNED TITLE - DATE <br /> i <br /> {SY SANT <br /> HI <br /> Di/ED <br /> 1 2019 <br /> U;N COUNTY <br /> SIR Nt1AENTAL <br /> H T EPARTMENT <br /> gal=# <br /> EP RTMENT U E NLY ��f7 <br /> Application Accepted By ate Area Employee IDM g�i f'� <br /> Grout Inspection By Date z SPECIAL Well Perrnit <br /> Pump Inspection By Date WAIVER Received <br /> Sod Boring Inspection By Date Constructed Well Depth h <br /> COMMENTS <br /> PE SC ReceivedChockMJ: Amount Pe <br /> rmiU <br /> Codes Info ittod Date Service Ra uest M Invoice M Well IDM <br /> - em <br /> Pal q? �ICWJL <br /> 30(14 :?4�LI<-Y11tfi1 rn <br /> EMO UA9,wsa�U1�n9 .1f t I rt'yNv Pg RHI: <br />