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r WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDA9L9 PERMIT www.sjgov.org/ohd EXPIRES 7 YEAR FROM DATE ISSUED <br /> JOB ADDRESS SR 120 between Airport Way&S.Main St CrrY/ZIP Manteca,95337 <br /> D <br /> CROSS STREET Union Road APN N/A PARCEL SIZE LAND USE APPLICATION# O <br /> A <br /> OWNER NAME Caltrans Right of Way PHONE N/A y <br /> OWNER ADDRESS N/A CITYISTATEIZIP <br /> CONTRACTOR Geo-Ex Subsurface Exploration PHONE 916-799-8198 <br /> CONTRACTOR ADDRESS 1510 Madera Drive, CITYISTATE/ZIP Dixon,CA 95620 <br /> SUBCONTRACTOR/CONSULTANT Parikh Consultants,Inc PHONE 916-516-1304 <br /> SUBCONTRACTORICONSULTANT ADDRESS 1497 N.Milpitas Blvd CITYISTATE/ZIP Milpitas,CA 95035 <br /> LICENSE x C-57 i i C-61 a D-09 ❑Other NUMBER 954267 ExPIRATIONDATE 7/31/20 <br /> BILLING PARTY: ❑OWNER G CONTRACTOR x SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPUNG:•.General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring x Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK G New Well =Replacement Well E Well Alteration/Modification Other <br /> ❑Monitoring Well(s) #of wells o Soil Boring(s) #of borings x Geotechnical 12 #of borings <br /> ❑Out-Of-Service Well O Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pum Pump Replacement ❑Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary F-.1 Air Rotary x Auger I;Cable Tool o Push Point Other <br /> Proposed Well Depth 40 ft Excavation 8 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 I Stainless Steel ❑Other <br /> Grout Seal Depth 40 ft x Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> Ej Bentonite(20%solids) Other <br /> Grout Placement Method ❑Pumped Free Fall x Other Tremie Pipe ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller -i Pump Contractor ❑ Other <br /> J Concrete Pedestal i'Dimensions:Width ft Length 1t Thick in ❑Christy Box ❑Stove Pipe <br /> ---------- <br /> auMP -Submersible-Turbine n 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 TITLE Associate DATE 5/7/2020 <br /> Aq <br /> FCF��NT ; <br /> FO <br /> qy 0,;' ?0? <br /> q QU/N 0 <br /> N� <br /> DEPARTMENT <br /> ---'U Y <br /> Application Accepted By Date s � ��� Area S A+!rtML <br /> Employee[D# SF <br /> Grout Inspection By Date 11 SPECIAL Well Permit <br /> Pump Inspection By Date 1_I WAIVER Received <br /> Soil Boring Inspection By 7r Date 17 W Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> 43�a so la <br /> EHO43-06 8111r2019 WELL]PUMP PERMIT <br /> `082�'`/aZS <br />