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t WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Sedan Avenue <br /> JOB ADDRESS J CITy21P Manteca,CA 95337 <br /> Manteca Road 22610042 29.95 acres e <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION o <br /> P <br /> OWNER NAME Megan Stover C/o Richmond American homes(for Owner) PHONE 707-689-7337 <br /> OWNER ADDRESS One Harbor Center,Suite 100 CITY/STATE/ZIP Suisun City,CA 94585 <br /> CONTRACTOR Middle Earth Geo Testing,Inc. PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 N.Lemon Street CITY/STATE/ZIP Orange,CA 92867 <br /> SUBCONTRACTOR/CONSULTANT Mid Pacific Engineering,Inc.(MPE) PHONE 916-927-7000 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 840 Embarcadero Drive,Suite 20 CITY/STATEJZIP West Sacramento,CA 9�j5605t* <br /> LICENSE )(C-57 C-61 D-09 Other NUMBER 899451 EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMFsTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomestictPrivate 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 AlterationlModification '(Other 3 CPTS <br /> Monitoring Well(s) #of wells Soil Boring(s) a of borings Geotechnical #or bongs <br /> Out-Of-Service Well Out-0f-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 Auger Cable Tool Push Point Other <br /> Proposed Well Depth 50 It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter 2 in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 it (Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall .Other IC Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller - Pump Contractor "- Other <br /> Concrete Pedestal Dimensions:Width ft Length It 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 ORDftNCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND A W TH THE CALJF4PNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE TIO LA <br /> MINIMUM 4 R A E REQUIRED FO SPECTt PLErASE CALL(209 953-7697 <br /> SIGNED TITLE %4PLEASE <br /> DATE 06.09-2021 <br /> lei P IA <br /> iAENT <br /> EIVED <br /> 0 9 2021 <br /> NMENTALTMTM <br /> HEALTHEPARTMENTTEI_ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By z7 Date I Area J !°+unkut Employee ID#� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inscoon ey Date Constructed Iryell Depth ft <br /> COMMENTS /r eY„MI p e f (,t il.P r F P Row -#,v- <br /> V6n 3 J! <br /> PE SC Received Check#/ Amount Date Pertnitl Invoice# Well ID# <br /> Codes Info Remitted Se eRe uest# <br /> 37a so760 <br /> EI4p43-0E 6/112019 <br /> WELL/PUMP PERMIT <br />