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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205-6232 (209) 4683420 ll L�ll`Ilii3;ir�_1J R3J3:IP�11. ADDRESS 19012 CALLA DRIVE STREET STATE HIGHWAY 120 APN 228-030-48 .NAME DAVID WAYNE & ANNE MARIA BOERSMA 19012 CALLA DR TANT TRACTOR/CONSUL7ANT ADDRESS D C-57 n C-61 ❑ D-09 ❑ Other. PARTY: D1 OWNER C CONTRACTOR CITY/ZIP MANTECA 95336 PARCEL SIZE 60 ACRESAND USE APPLICATION PHONE 209-613-0055 CITY/STATE/LP MANTECA CA 95336 PHONE CITYISTATEIZIP PHONE CITYISTATEIZIP NUMBER EXPIRATION DATE_ ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑Arsenic (4393) INTENDED USE DS Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization U Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well 11 Well Alteration/Modification 11 Other n Monitoring Wells) # of wells 0 Out -Of -Service Well FXNAW Pumn n Pumn Ra-nlaramanT 17 Soil Boring(s) #of borings n Geotechnical ❑ Out -Of -Service Well Renewal CI Cross -Connection Repair -1 Pumn Rannir f I PniQa Wall r'.=cinn # of borings WELL CONSTRUCTION 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, Inspection Drilling Method n Mud Rotary ❑ Air Rotary n Auger n Cable Tool a Push Point ❑ Other Proposed Well Depth it Excavation in diameter n Open Bottom ❑ Gravel Pack/Gravel Size in diameter Well ID# n Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTM Schad n Steel ❑ Plastic ❑ Stainless Steel n Other Grout Seal Depth ft n Neat Cement (94 lb bag/540 gal water) n Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) n Other Grout Placement Method n Pumped ❑ Free Fall u Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By n Driller . Pump Contractor 11Other Concrete Pedestal LlDimensions: Width ft Length Itit Thickin LlChristy Box n Stove Pipe As PUMP ❑ Submersiblen Turbine n Other HP Z. Pump Set It Standing Water Level ft I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. %fyFF��11MUJ�A 4�HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953411"17 SIGNED V'--'� % J K� TITLEl/ IV1i��Q-� DATE ` a I T ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Al Inspection By Date Amount Remitted Date Permit/ ice Re uest# Invoice # Well ID# ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�r:i , ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Grout Inspection By Date Amount Remitted Date Permit/ ice Re uest# Invoice # Well ID# C7 SPECIAL Well Permit WAIVER Received Constructed Well Depth ft PE Codes SC Info Received Check#/ Amount Remitted Date Permit/ ice Re uest# Invoice # Well ID# HD43-06 6111/2019 WELL /PUMP PERMIT rM►�nlT %6 9 209 L 1 n MENT