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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 />IN-KEFUNDABLE PERMIT orl www.sigov.orgierld <br />ADDRESS 13039 S HWY CIT,,/Zip Manteca 95336 <br />SS STREET LATHROP RD APN 20405047 PARCEL SIZE LAND USE APPLICATION # <br />IER NAME Clarke & Judith Marek PHONE 209-823-0110 <br />IER ADDRESS 13101 S HWY 99 CITY/STATE/ZIP MANTECA CA 95336 <br />CONTRACTOR GOLDEN STATE IRRIGATION & PUMP SERVICE <br />CONTRACTOR ADDRESS 4500E. FREMONT <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE CI C-57 r)(C-61 ❑ D-09 Ii Other <br />BILLING PARTY: G OWNER XONTRACTOR <br />PHONE 209-943-7774 <br />Cm/STATE/ZIP STOCKTON, CALIF 95215 <br />CITY/STATE/ZIP. <br />NUMBER 979833 <br />0 SUBCONTRACTOR/CONSULTANT <br />PHONE <br />E%PIRATION DATE 12/31/22 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) I7 Dibromochloropropane (4392) 11 Arsenic (4393) <br />NTENDED USE L)(Domestic/Private ❑ Irrigation/Agricultural [J Industrial I I Water Quality Monitoring II Soil Sampling/Characterization <br />F] Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well : Replacement Well I Well Alteration/Modification 11 Other <br />rI Monitoring Well(s) # of wells I I Soil Boring(s) # of horings Geotechnical # of borings <br />i ] Out -Of -Service Well I1 Out -Of -Service Well Renewal 1 ] Cross -Connection Repair <br />ED <br />)rllling Method ❑ Mud Rotary fJ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />eroposed Well Depth ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br />o Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad " Steel Plastic ; I Stainless Steel I' Other <br />Grout Seal Depth ft r Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixr7 gal water <br />I Bentonite (20% solids) ❑ Other <br />3rout Placement Method r1 Pumped i I Free Fall i I Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By !1 Driller ❑ Pump Contractor I I Other <br />LI Concrete Pedestal LIDlmensions: Width ft Length ft Thick in CI Christy Box 'i� Stove Pipe <br />PUMPX Submersible) Turbine ❑ Other HP 3 Pump Set 80 ft Standing Water Level a4 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 ANDVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS CKP5. <br />MINH V NCE NOTICE REQUIRED FO PECTIIFPNS (PLEASE CALL (209) 953- 697 <br />SIGNED TITLE � l �i DATE Zy Z <br />7 � <br />J0 <br />Z <br />✓) Z <br />rn <br />;i7 D <br />< I— <br />:� 2 <br />D <br />1177 <br />DEPARTMENT USE ONLY <br />Application Accepted By �—'�— Date / /� Area Szq2 Employee ID# J� <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date , 7-0�Z El WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS c.'S �.-. (1r4� �M. /.Ci C�^ Lt .0 ir�Ll l� �r LA <br />EHD 43-06 6/112019 lJJ/ ® 1_:1Y2_!`-1 // WELL /PUMP PERMIT <br />ANT <br />FD <br />2021 <br />outvey <br />rq <br />114r <br />