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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />WKEFUNDABLE PERMIT www.sjgov.org/ena tAPIKtJ l TEAR FF <br />ADDRESS 438 Cottage Avenue CITy/ZIP Manteca/95336 <br />SS STREET E Alameda St APN 208-23-063 PARCEL SIZE 0.14 Acres LAND USE APPLICATION # <br />IER NAME Anthony Barkett, RAYB Development LLC —DFA Deveiapme'nl PHONE 209-541-5397 <br />IER ADDRESS 119E Weber Avenue Crry/STATEMp Stockton/CA/95202 <br />West Coast Exploration Inc PHONE 209-985-7541 <br />ADDRESS P.O. Box 133 Cm/STATE/MP Escalon/CA/95320 <br />TANT CTE CAL Inc <br />TANT ADDRESS 4230 Kiernan Ave Ste 150 <br />LICENSE x C-57 C-61 D-09 Other <br />BILLING PARTY: OWNER CONTRACTOR <br />PHONE 209-543-1799 <br />CITY/STATE/ZIP Modesto/CA/95356 <br />NUMBER 870761 EXPIRATION DATE 1/31/2022 <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE 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 />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Bodng(s) # of borings x 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 x Auger Cable Tool Push Point Other <br />Proposed Well Depth 20 It Excavation 4 inches in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth90 It x Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped x 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 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ZIP" (i 'Sli" �l p TITLE Staff Geologist DATE 6/30/2021 <br />f/1 <br />g <br />N <br />DEPARTMENT USE ONLY <br />Application Accepted By !f Date % Area r�r�.�.64mployee ID# A <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By 4 Date WAIVER Received <br />Soil Boring Inspection By , _D % <br />/ato —1 Constructed Well Depth ft <br />COMMENTS SIC 6YJU 'W� kr elme JI'll Yf7Wa */emmu4-_Al:xi0e_tv 4P <br />PE Sc Received Check#1 Amount D to Permit/ <br />Invoice # Well ID#Codes Info Remitted ee e uest <br />% <br />EHD43-06 6/11/2019 AW <br />/ 2S f 0 L ?S_ WELL/PUMP PERMIT <br />