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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 96205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT C - ....... <br />JOB ADDRESS 330 S Garfield Avenue <br />•...•••• IN,s1 I....a. I I crux rrtum LIR I C loamy <br />cirazip Manteca/95336 6, ..r. <br />CROSS STREET Mikesell Avenue APN 221-180-130-000 PARCEL sizd 0.57 acreiA „ I./SE <br />m r. <br />8 <br />OWNER NAME Manteca Unified School District <br />ND APPLICATION # <br />PHONE (209) 825-3200 E <br />2271 W. Louise Ave OWNER ADDRESS Manteca/CA/95336 CITY/STATE/ZIP <br />V? <br />V&W Drilling CONTRACTOR PHONE (209) 469-7700 <br />1133 Blackhurst Drive CONTRACTOR ADDRESS Crry/STATE/ZIP Galt/CA/95632 <br />SUBCONTRACTOR Wallace-Kuhl & Associates PHONE (916) 372-1434 <br />SUBCONTRACTOR ADDRESS 3050 Industrial Blvd. City/STATE/Zip West Sacramento/Ca/95691 <br />LICENSE )4 C-57 :: C-61 : ' 0-09 E Other NUMBER 720944 EXPIRATION DA 4/30/24 TE <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE L Domestic/Private 2 Irrigation/Agricultural D Industrial L. Water Quality Monitoring I* Soil Sampling/Characterization <br />: Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF Woes El New Well LI Replacement Well Li Well Alteration/Modification u Other <br />Li Monitoring Well(s) # of wells 0 Soil Boring(s) i of Owings X Geotechnical 10 #01 borings <br />[i Out-Of-Service Well 0 Out-Of-Service Well Renewal LI Cross-Connection Repair <br />[1 New Pump — Pump Replacement 0 Pump Repair Li Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ,:l Mud Rotary [1 Air Rotary X Auger D Cable Tool L Push Point 0 Other <br />Proposed Well Depth 5-30 ft Excavation in diameter 0 Open Bottom U Gravel Pack/Gravel Size in diameter <br />L Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/GaugeJASTM Sched 0 Steel 0 Plastic LEI Stainless Steel 0 Other <br />Grout Seal Depth 5-30 tt x Neat Cement (94/b bag/5-10 gal water) I.1 Sand Cement sack mbd7 gal water <br />L Bentonite (20% solids) El Other <br />Grout Placement Method LI Pumped X Free Fall LI Other Tremie if water G Retardant / Accelerator (name) <br />PAYMEI PEDESTAL Installed By I - Driller E Pump Contractor II Other <br />LJ Concrete Pedestal El Dimensions: Width ft Length ft Thick RECE1V in E Christy Box L_ Stove Pipe <br />PUMP Submersible Turbine E Other HP Pump Set ft Standing Water Level <br /> ma <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, AINetQUI COUNTY <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For D <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. HEAL <br />Vgar <br />EARTMENT <br />ll.IsIL I 24 HO( it %DS AIS4 I( 1,, REWIRED MR 1NSPt crioNis - PLEASE CALI (209) 953-7697 <br />N ENTAL <br />2072 <br />DEPARTMENT USE ONLY <br />Application Accepted By <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area 3/1114 04e(41 Employee ID# (.7 <br />O SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth ft <br />Date <br />15127, <br />PE <br />Codes <br />SC <br />Info <br />Received <br />y <br />Check*/ <br />Cash <br />Amount <br />,Remitted Date „ ...., <br />PermIV <br />Service Request it Invoice* Well ID* <br />437d i S-6 <br />Ap <br />5/-1 D f I 8,3") :1101Z2- LURIbli-?20 iCP <br />- <br />ER1)043-06 16,25,2021 Pug • I of 2 Well / Pump Permit