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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT CALL (LUU) U0J-/by/ FOR INSPECTIONS tX1J1KtJ I YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />I / / / West Yosemite Avenue <br />CITY2IP <br />Manteca, CA 95337 <br />CROSS STREET <br />St. Domlriics Drive <br />APN 20018034 <br />PARCEL SIZE 5.96 aEAND USE APPLICATION # <br />OWNER NAME <br />Kaiser Permanente — <br />K0v3Y Foi r)1 <br />&Jk NoSA�dS <br />PHONE 209-825-3700 <br />Depth ai 6 ft <br />P14 <br />sack mi c <br />k 1�, d gy61 of <br />OWNER ADDRESS <br />e e -46r zo, <br />_ IS � <br />CITY/STATE/ZIP <br />��, n <br />CONTRACTOR <br />Atlas Technical Consultants <br />PHONE 510-566-0809 <br />CONTRACTOR ADDRESS 2001 Crow Canyon Road CITYISTATE/ZIP <br />SUBCONTRACTOR West Coast Exploration, Inc. <br />San Ramon/CA/95822 <br />PHONE 209-985-7541 <br />SUBCONTRACTOR ADDRESS PO Box 133 CITY/STATE/ZIP Escalon/CA/95320 <br />LICENSE V-57 C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 01/12/2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (439) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring VSoil 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 Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical _C# of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New PumD Pump ReDlacement Pump Repair Raise Well Casino <br />WELL CONSTRUCTION �� <br />Drilling Method Mud Rotary Air Rotary -/Auger Cable Tool PushOther <br />P <br />A <br />Proposed Well <br />Depth 20 ft <br />oint <br />Excavation 3 in diameter Open Bottom Gravel Pack/Gravel Size <br />4 Coe 22 <br />Conductor Casing <br />in diameter / Conductor Casing Depth ft <br />Well Casing <br />Diameter in Thicknes4Gauge/ASTM Sched Steel Plastic Stainless Steel <br />Other 1A At <br />Grout Seal <br />Depth ai 6 ft <br />'Neat Cement (94 Ib bag/5-10 gal water) Sand Cement <br />sack mi c <br />Bentonite (20% solids) <br />Other <br />SAN N. in. — <br />Grout Placement Method Pumped <br />Free Fall Other Retardant / Accelerator (name) <br />, ,_ENVIRn <br />PEDESTAL Installed By Driller Pump Contractor Other �i <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />�in Christy Box Stove Pipe <br />PUMP 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By G Date f eb ) <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspectiogj By Date <br />COMMENTS -ffem le -fn h,2 .jSPe4 I ezroo."dV4A } <br />Area ; m4n4« Employee ID#� <br />SPECIAL Well Permit <br />WAIVER Received <br />Well Depth <br />ft <br />W <br />IT <br />D <br />PE <br />Codes <br />SC Received Check#/ <br />Info B Cash <br />Amount Date ermit/ Invoice # Well ID# <br />Remitted Service Request # <br />-79 <br />6-0 <br />4 Coe 22 <br />EHDO43-06 10/25/2021 Page I of 2 Well / Pump Permit <br />�Tw x/37//2/7 <br />Ty <br />Ir <br />