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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT www.slgoy.Org/end EXPIRES 7 YEAR FF <br />JOB ADDRESS 1069 S Airport Way Cm/zIP Manteca 195242 <br />Z413fU42, 24T31U39 <br />CROSS STREET Daniels St APN 24131038, 24131043 PARCEL SIZE .7 L LAND USE APPLICATION # <br />OWNER NAME Leu'Ick V j -yr ehF PHONE <br />OWNERADDRESS SC -W91 CITY/STATE/ZIP <br />CONTRACTOR Neil O' Anderson and Associates <br />CONTRACTOR ADDRESS 902 Industrial Way <br />PHONE (209) 588-2219 <br />CrrY/STATEZP Lodi, CA 95240 <br />SUBCONTRACTOR/CONSULTANT Same as above PHONE Same as above <br />SUBCONTRACTOR/CONSULTANT ADDRESS Same as above CITY/STATEZP Same as above <br />LICENSE )( C-57 C-61 i D-09 Other NUMBER #669004 EXPIRATION DATE 05/31/2023 <br />BILLING PARTY: OWNER i�CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 1 New Well Replacement Well Well Alteration/Modification i Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of honogs 7{ Geotechnical 8 # of bodngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />3rilling Method Mud Rotary ! 1 Air Rotary )( Auger j Cable Tool Push Point 1 Other <br />3roposed Well Depth 5 to 50 ft Excavation 6 114" in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth 5 t050 ft )( Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />3rout Placement Method XPumped Free Fall Other - Retardant / Accelerator (name) <br />PEDESTAL Installed By fl Driller -� Pump Contractor i Other <br />? Concrete Pedestal ! ]Dimensions: Width It Length ft Thick in f Christy Box rl 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_ ._ -_ �� TITLE Staff Engineer DATE 11/24/2021 <br />R IM <br />ik <br />® ® <br />A _ spa.: <br />i`•h ..7V-� <br />ZZ <br />DEPARTMENT USE ONLY <br />L <br />Application Accepted By Date Area a ?n6014R, Employee ID# A -S <br />Grout Inspection By Dale" Z SPECIAL Well Permit <br />Pump Inspection By Data ��TT��WAIVER Received <br />Soil Boring Inspection Bypp Date Constructed Well Depth ft <br />COMMENTS � o}C9I tr R boi-la c C14 5%In:(4 CI hL e IS 6 P (1 �1- 47A �P )Qy'­ j16j . <br />YMENT <br />0 1 2021 <br />JOAQUIN COUNTY <br />TH DEPARTMENT <br />EHD43-O6 6/11/2019 WELL/PUMP PERMIT <br />