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WELL/PUMP PERMIT <br />Or C. h cvr <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />INUIN-KEFUNDABLE PERMIT <br />UALL (LUU) `J,J-/bUf FUR INSPEGTIUNS <br />CAYIKC0 T T LAK FRUM UA I t ISSUtU <br />Joe ADDRESS 2103 S Austin Rd <br />CITY/ZIP <br />Manteca 95336 <br />CROSS STREET Moffat Blvd <br />APN 224-05-019 PARCEL SIZE 26.12 <br />LAND USE APPLICATION # <br />OWNER NAME Veldstra, George <br />PHONE (209) 823-5380 <br />OWNER ADDRESS 310 Flores Ave <br />CITY/STATE/ZIP <br />Manteca, CA, 95336 <br />CONTRACTOR Blackbum Consulting <br />PHONE (916) 375-8706 <br />CONTRACTOR ADDRESS 2491 Boatman Avenue <br />CITY/STATEMP West Sacramento, CA, 95691 <br />SUBCONTRACTOR Taber Drilling <br />PHONE (916) 371-8234 <br />SUBCONTRACTOR ADDRESS 536 Galveston St <br />CITY/STATE/ZIP <br />West Sacramento, CA, 95691 <br />LICENSE A C-57 C-61 D-09 - <br />Other NUMBER 969927 <br />EXPIRATION DATE 02/29/2020 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring ix 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 Alteration/Modification J Other <br />Monitoring Well(s) # of wells 'S Soil Boring(s) # of bodngs x Geotechnical 1 # of borings <br />Out -Of -Service Well i i Out -Of -Service Well Renewal I1 Cross -Connection Repair <br />i 1 New Pump i Pump Replacement ❑ Pump Repair C Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method i i Mud Rotary i Air Rotary A Auger n Cable Tool i Push Point Other <br />Proposed Well Depth 5 ft Excavation 4 in diameter - Open Bottom i Gravel Pack/Gravel Size in diameter <br />I i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I Steel iPlastic i i Stainless Steel i Other <br />Grout Seal Depth ft I Neat Cement (94 /b bag/5-10 gal water) i Sand Cement sack mixf7 gal water <br />i i Bentonite (20% solids) i Other <br />Grout Placement Method i Pumped i : Free Fall i_ Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By -i Driller i Pump Contractor r7 Other <br />i Concrete Pedestal iDimensions: Width ft Length ft Thick in i Christy Box I i Stove Pipe <br />PUMP i Submersible i Turbine i 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 />70n <br />R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />IGNED TITLE VP / Exploration Coordinator �� L? -)DATE 02.06.2019 <br />812019 1?019 <br />I/N � <br />M�NTUN7'y <br />DEP 'HENT U E NL <br />Application Accepted By Date t Area C0� Employee ID# <br />Grout Inspection <br />onTn B Date I S ECIAL Well Permit <br />Pump Inspec Date I WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />7 <br />EHD 43-06 revised 4/14/18 <br />WELL /PUMP PERMIT <br />EHD 43-06 revised 4/14/18 <br />WELL /PUMP PERMIT <br />