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I <br />WELL/PUMP PERMIT / <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 19667 S. Jack Tone Rd. -7 C CITYIZIP Manteca 95336 <br />CROSS STREET N. of Graves Rd. APN 228-070-06 PARCEL SIZE 39 48LAND USE APPLICATION# <br />OWNER NAME Rosa Farms Family LP-(_ PHONE 595-2566 Grant <br />OWNER ADDRESS 12100 L. Graves Rd. CtTYISTATE/ZIP Mantera, CA g9336 . <br />CONTRACTOR Hennings Bros. Drillinq Co., Inc. PHONE 545-1185 <br />CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/Zip_lylodesto CA 95356 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 290813 EXPIRATION DATE -5-31 -2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE Domestic/Private iXlnigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Uontact Name or Phone Number <br />TYPE OF WORK New Well XReplacement Well L Well Alteration/Modification Other <br />MonitoringWell(s) #of wells ❑ Soil Boring(s) #ofbodngs Geotechnical #of borings <br />Out -Of -Service Well C Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement I i Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method XMud Rotary Air Rotary Auger Cable Tool Push Point X Other Reverse Rotary <br />Proposed Well Depth 500 ft Excavation 26 in diameter Open Bottom XGravel Pack/Gravel Size NO. 6 in diameter <br />XConductor Casing 3— in diameter / Conductor Casing Depth 150 ft Sand Pack <br />Well Casing Diameter __16 in Thickness/Gauge/ASTM Sched 1 /4ga XSteel Plastic Stainless Steel Other <br />Grout Seal Depth 150 ft L Neat Cement (94 /b bag/5-10 gal water) Sand Cement 10.3 sack mixR gal water <br />Bentonite (20% solids) C Other <br />Grout Placement Method XPumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller XPump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set It 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 />111ININIIIIU hd NnIIR enveNrP MOTIrF RPOUIRED FOR INSPECTIONS <br />;e PresidentDATE March 16, 2018 <br />ur <br />D <br />0 <br />A <br />w <br />Application Accepted By <br />EPA TMENT U E O ICY <br />• QJi <br />Date <br />Area Employee ID# <br />Grout Inspection By <br />Date <br />SPECIAL Well Permit <br />Pump Inspection By <br />Date <br />WAIVER Received <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth <br />ft <br />COMMENTS)/ZUf <br />�/ 'CO r r.PJN//J�� � <br />ArL <br />EHD 43-06 <br />8/04/08 <br />WELL /PUMP PERMIT <br />1 <br />C <br />