Laserfiche WebLink
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/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> _w <br /> JOB ADDRESS 915 W Lathrop Rd CITYIZIP Manteca/95336 <br /> D <br /> CROSS STREET Sherwood Ave APN 197-020-10 PARCEL SIZE 0.34 acres LAND USE APPLICATION# <br /> In <br /> OWNER NAME City of Manteca PHONE (209)456-8000 rn <br /> OWNER ADDRESS 1001 W Center St CITY/STATE/ZIP Manteca/CA/95336 <br /> CONTRACTOR Taber Drilling PHONE (916)371-8234 <br /> CONTRACTOR ADDRESS 536 Galveston St CITY/STATE/ZIP West Sacaramento/CA/95691 <br /> SUBCONTRACTOR/CONSULTANT Blackburn Consultina PHONE (530)902-6600 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 2491 Boatman Ave CITY/STATE/ZIP West Sacramento/CA/95691 <br /> LICENSE T C-57 ❑C-61 i7 D-09 Ll Other NUMBER 969927 EXPIRATION DATE 2/28/22 <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR x SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:LI General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial U Water Quality Monitoring ix Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well -,Replacement Well ❑Well Alteration/Modification Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings 2;Geotechnical 1 #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary b Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 35 ft Excavation 6 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth entire ft w Neat Cement(94 Ib bagl5-10 gal water) ❑Sand Cement sack mixf7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method &Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box :-i Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑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 /> fUM R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Vice President DATE 04.02.2020 <br /> EFNT <br /> l vF6 <br /> N ?0?0 <br /> R M ANT Y <br /> ENT <br /> DEPARTMENTV77 ONLY <br /> Application Accepted By �— /�"" L Data 7 ZD Z 0 Area MKn+ Employee ID# OA <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By } Date WAIVER Received <br /> Soil Boring Inspection By I �+ t_Jl \e G!i ;�,Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Re uest# <br /> 437.1 !S a ys6 <br /> EHD 43-08 6/112019 � y��r��� WELL/PUMP PERMIT <br />