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Benjamin Lopez Ortega <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE. STocKTGN CA 95205-6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 4855 Brunswick Road cryizip Manteca, 95336 <br />CROSS STREET Frontage 99 APN 19704010 PARCEL SIZE 4.48 ac LAND USE APPLICATION # <br />PHONE 2092722184 <br />5500 Vineyard Point Court cnyisTATEjzip Salida, CA 95368 <br />±16-dted <br />WELL /PUMP PERMIT EHD 43-06 6/102019 <br />112-3OS-Is-75-- <br />PHONE <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />CITY/STATE/ZIP <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE C-57 C-61 D-09 Other <br />BILLING PARTY: X OWNER <br />CITY/STATE/ZIP <br /> NUMBER EXPIRATION DATE <br />SUBCONTRACTOR/CONSULTANT CONTRACTOR <br />Well Alteration/Modification Other TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical #0/ borings <br />Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br />x New Pump Pump Replacement Pump Repair Raise Well Casing <br />Other Retardant) Accelerator (name) <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> <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 ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixf1 gal water <br />Bentonite (20% solids) Other <br /> <br />Grout Placement Method Pumped Free Fall <br />Other Installed By x Driller Pump Contractor <br />x Concrete Pedestal Dimensions: Width 10 ft Length 10 <br />DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />HP 5 Pump Set 2°° ft Standing Water Level 8° PUMP x Submersible Turbine Other ft <br />in Christy Box Stove Pipe ft Thick 4 <br />PEDESTAL <br />INTENDED USE x Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <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 />INIMUM 48 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 4 <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />SIGNED-6;0/W / 4 TiTLE owner DATE 3/31/2021 <br /> <br />Grout Inspection By Date <br />Pump Inspection By Ci.12031101466,Vlet <br /> <br />Soil Boring Inspection By Date <br /> <br />COMMENTS pt a hit I P S-04„4 <br />DEPARTMENT U ONLY <br />Application Accepted By Date ti <br />S <br />Area 3fri Employee ID# 6 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Date s 3 ( <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Sily, <br />Checkft/ <br />Cap , <br />Amount <br />Remitted ate Permit/ <br />Service Request # Invoice # Well ID# <br />4380 OS) ea& etted'rt- 31c.)5 2,I Wpaii-lopl