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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-61232 (209)465-3420 <br />NON-REFUNDABLE PERMIT www,sjgov.org/ena tX101Kt, l YEAR FROM L1ATE ISSUED <br />JOB ADDRESS 8301 Sedan Avenue CITY2IP Manteca/95337 <br />CROSS STREET Alice Avenue APN 226-120-17 PARCEL SIZE 9.83 ac- LAND USE APPLICATION # <br />Karen Ann Macedo Cambra, as successor trustee of the John Joseph Cabra and Karen Ann Macedo <br />OWNER NAME Cambra Revocable Trust PHONE <br />OWNER ADDRESS 2014 Oleander Avenue CITY/STATEMP Manteca/CA/95337 <br />CONTRACTOR Salem Engineering Group, Inc. PHONE 559-271-9700 <br />CONTRACTOR ADDRESS 4729 W. Jacquelyn Avenue cITY/STATE/ZJP Fresno/CA/93722 <br />SUBCONTRACTOR/CONSULTANT Salem Engineering Group, Inc. PHONE 559-271-9700 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 4729 W. Jacquelyn Avenue CITY/STATE/7JP Fresno/CA/93722 <br />LICENSE /C-57 C-61 D-09 Other NUMBER 970772 EXPIRATION DATE March 31, 2022 <br />BILLING PARTY: OWNER JCONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring VSoil 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 Altera6on/M ificatton Other <br />Monitoring Well(s) # of wells /Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Or -Service Well Out-Of-Servic Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary /Auger Cable Tool Push Point Other <br />Proposed Well Depth 50 ft Excavation 6 5/8 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 Depth 50 ft /Neat Cement (941b bag15-10 gal water) Sand Cement sack mix77 gal water <br />Bentonite (20% solid -lie' Other <br />Grout Placement Method Pumped gree Fall Other tremmle 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 It Standing Water Level It <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 48UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED C�e TITLE Geotechnical Staff Engineer DATE August 26, 2021 <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By T <br />L- Date C +�`'� Jt Area / Employee ID# 6 <br />Date SPECIAL Well Permit <br />Date `7d WAIVER Received <br />RFq�'MF <br />r <br />�0 31 4 <br />°q_40,,..?1 <br />