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- <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL ZU9) 953-7b9l FOR INSPECTIONS tAt'IKtS l YEAR FROM UATE ISSUED <br />JOB ADDRESS 955 S. Airport Way CITY/ZIP Manteca <br />CROSS STREET State Highway Route 120 APN 241-333 y�ZO�ly� PARCEL SIZE 35.91 acres <br />LAND USE APPLICATION # <br />OWNER NAME Lorene Clauser / (6C kci e I G_auLs-e.t- /1611 6 �h O'c"t, St) PHONE (209) 629-8864 <br />OWNER ADDRESS <br />955 S. Airport Way — P J ��) �� I -t+ CITY/STATE/ZIP Manteca 3� <br />CONTRACTOR West Coast Exploration, Inc. <br />CONTRACTOR ADDRESS P.O. Box 133 <br />SUBCONTRACTOR Stevens, Ferrone & Baile <br />SUBCONTRACTOR ADDRESS 1600 Willow Pass Court <br />CITY/STATE/ZIP <br />Enqineerinq Company, Inc. <br />LICENSE x C-57 C-61 D-09 Other <br />CITYISTATE/ZIP <br />NUMBER 870761 <br />PHONE (209)985-7541 <br />Escalon, CA 95320 <br />PHONE (925)688-1001 <br />Concord, Ca 94520 <br />EXPIRATION DATE 01/31/2023 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (439 1) 0 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED 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 <br />New Well Replacement Well Well Alteration/Modification Other <br />3 7,2i� �3�. t' �� 22 <br />.� 2-0 <br />1.1 Monitoring Well(s) # of wells x Soil Boring(s) 7 # of Dorings Geotechnical <br /># of borings <br />I Out -Of -Service Well Out -0f -Service Well Renewal Cross -Connection Repair <br />PgyMEr <br />New Pum Pum Replacement Pum Repair Raise Well Casing7i. <br />WELL CONSTRUCTION <br />Drilling Method <br />Mud Rotary Air Rotary x Auger Cable Tool Push Point Other <br />Proposed Well <br />Depth 1040 ft Excavation 4 in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth __._ft <br />SAN JO <br />Well Casing <br />Diameter N/A to Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel <br />-Othh& p QU/N <br />FHf d6ri i IRS <br />Grout Seal <br />Depth 10-40 ft x Neat Cement (94 Ib bagl5-10 gal water) Sand Cement <br />/0 <br />Bentonite (20% solids) Other Trenue if <br />- <br />Grout Placement Method i l Pumped Free Fall x Other groundwater is Retardant / Accelerator (name) <br />onrniin ora <br />PEDESTAL N/A Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length ft Thick <br />in Christy Box Stove Pipe <br />PUMP N/A Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />NIINIMt'1V1 24 110t;R ADVANt F NOTICE REQUIRED FOR INSPECf1UNS - I'I F \',I ( AI I. (2091'153-7097 <br />DEPARTMENT USE ONLY <br />Application Accepted By _t -j' ,7 Iil/ Date .2 .�� Area 1� t;r°tFcc-, Employee ID# j <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date 1 ❑ WAIVER Received <br />Soil Boring Inspection By/ Date `-%� — Constructed Well Depth ft <br />COMMENTS <br />+Y <br />0 <br />0 <br />z <br />M <br />N <br />Ty <br />PE SC Received Check#1 Amount <br />Codes Info S Cash Remitted Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />- <br />3 7,2i� �3�. t' �� 22 <br />.� 2-0 <br />EI1W43-06 102512021 I'a<< ort well I'un>n tenni, <br />