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182Q <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 4683420 <br />rV WI1V_ CtrunL)AtsLt rtKMI I www.sjgov.org/ena EXPIKES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5836 E. Northland Rd. _ _ _ CITY/ZIP Manteca/95336 <br />CROSS STREET S. Frontage Rd. APN 197-08-023 PARCEL SIZE 1.02 LAND USE APPLICATION # <br />OWNER NAME Matt Robinson PHONE 925-484-8697 <br />OWHERADDRESS SAME CITYISTATE/ZIP <br />CONTRACTOR Delta Pump Co. PHONE 209-466-%25 <br />CONTRACTOR ADDRESS 646 S. California St. CrTYtSTATEMP Stockton/CA/95203 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOWCONSULTANT ADDRESS <br />CrrY(STATE21P <br />PHONE <br />CENSE X;;-61 D-09 Other NUMBER 1055434 EXPIRATION DATE7131/2023 <br />131!2023 <br />ILLING PARTY: OWNER CONTRACTOR 11 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />�INTENoeo UsE � Domestic;Private � IrrigatiorUAgricultural -Industrial 'Water Quality Monitoring f' Soil Sampling/Characterization <br />Public Water System <br />— <br />r <br />Jrferere frarr Owrer. Waley System Name Contac) Name or phone Numbe• /I l+. _ <br />TYPE Or- WORK ! New Well 1. Replacement Well Well AfteratiorkiModification Other r C <br />-1 Monitoring Well(s) # of wells - Soil Boring(&) p et borings r- Geotechnical <br />Out -Of -Service Well Out -Of --Service Well Renewal Cross -Connection Repair _ __UCr 14 202, <br />New Pum Pum Replacement J Pum Repair _ Raise Well Casing7 <br />WELL CONSTRUCTION VI / QUI <br />Di illmg Method .J Mud Rotary L Air Rotary U Auger U Cable Tool _ Push Point Other HEq�RGNMEN r4l <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom i I Gravel Pack: Gravel Size 1r1Tct <br />J Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameter in Thick ness+Gauge.;ASTM Sched I I Steel Plastic i Stainless Steel Other <br />Grout Seal Depth ft _ Neat Cement (941b bag/r- 10 gal water) _ Sand Cement sack rna17 gal water <br />I Bentonite (20116 solids) i Other <br />Grout Placement Method _ Pumped J Free Fall _ Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />-1 Concrete Pedestal-10ime4Tsions Width ft Length ft Thick in - Christy Box rl Stove Pipe <br />PUMP X Submersible _ Turbine _ Other HP 1 Pump Set 60 ft Standing Water Level --aQ_ ft <br />1 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SONm •' ity�C<<--- ,. TITLE CEO - DATE 9/22/2021 <br />U YAK I PAIN 1 USt ONLY <br />Application Accepted By L-L� Date D ��/ % Area f'cicf Employee IDI/A6 <br />Grout Inspection By Date — I SPECIAL Well Permit <br />Pump Inspection By Date X213e) ( I WAIVER Received <br />Soil Boring Inspection B,yt� ` Date Constructed Well Depth It <br />COMMENTS _N\i�al� LnE� <br />PE <br />Codes <br />SC Received C k Amount <br />Info B Cash RemittedService <br />Date <br />Permit! <br />Reque.st # <br />Invoice# Well ID* <br />3?i <br />O_;"o -17-7 <br />EF -O 43 X 0, iP0'9 <br />1.14ELL TUR' f' PERMIT <br />