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Me <br /> i <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)466-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ebd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 19 Hwy 99 near Austin Rd Over Crossing CITY/ZIP Manteca/95336 6DD <br /> CROSS STREET Austin Rd APN 01-2 s"b07PARCEL SIZE NA LAND USE APPLICATION# A <br /> m <br /> OWNER NAME California Department of Transportation PHONE (20 9)948-7543 y <br /> OWNER ADDRESS 1976 E Dr Martin Luther King Jr.Blvd CRY/STATEIZIP Stockton/CA/95205 <br /> CONTRACTOR Blackburn Consulting PHONE (,916L)375-8706 <br /> CONTRACTOR ADDRESS 2491 Boatman Ave CITYISTATE/ZIP West Sacramento/CA/95691 <br /> SUBCONTRACTOR/CONSULTANT Taber Drilling PHONE (916)371-8234 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 536 Galveston Dr CITY/STATE/ZIP West Sacramento/CA/95691 <br /> LICENSE XC-57 C-61 D-09 Other NUMBER 969927 EXPIRATION DATE 2/28/2022 <br /> BILLING PARTY: OWNER XCONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromoohloropropane(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 New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(S) #of borings X Geotechnical 1 #or 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 X Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 35 it 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 X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped Free Fall Other _ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_ It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT t 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 /> U R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Executive Vice President DATE 10.23.2020 <br /> i YI SENT <br /> CES vrF1) <br /> T 8 2020 <br /> QUIIV C <br /> I HSA PARTT UNTY <br /> AL <br /> MENT <br /> /DEPARTMENT USE ONLY <br /> Application Accepted By �` Datea7 aO�A; Area_ Employee IN DAA <br /> Grout Inspection By Date 7Iv✓V SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth_ ft <br /> COMMENTS����a OOGG <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted S ice Request# <br /> J— Z <br /> EHD 43.06 BN 1/2019WELL/PUMP PERMIT <br /> 1/Sy'SvZa/ <br />