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DocuStgn Envelope ID: D5323C7A-9609-44E5-8C9E-4A7EBECODAB2 <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL LU`J 0011-fbUf FOR INSPECTIONS tArlKCJ I TEAR FROM DATE ISSUED <br />JOB ADDRESS 1241 North Main Street CITY/zIIP Manteca <br />CROSS STREET Lancaster Avenue APN 216-340-600 PARCEL SIZE 31 SL LAND USE APPLICATION # <br />925-999-0288 <br />OWNER NAME Kanwar[Gill PHONE <br />qySU% <br />OWNER ADDRESS l %o1 S.,S�rlo-�� C -i- CITY/STATE/ZIP AI -aw <br />CONTRACTOR V&W Drilling Inc. PHONE 209.469.7700 <br />CONTRACTOR ADDRESS 1133 Blackhurst Drive <br />SUBCONTRACTOR Geocon Consultants, Inc. <br />SUBCONTRACTOR ADDRESS 6671 Brisa Street <br />LICENSE X C-57 C-61 D-09 Other, <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP <br />Galt, CA 95632 <br />_ PHONE 925.371.5900 <br />Livermore, CA 94550 <br />NUMBER 720904 EXPIRATION DATE 4/30/2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED 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 />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />S rvice Re uest <br />Monitoring Well(s) # of wells Soil Boring(s) 4 of borings X Geotechnical <br />5 u of Y <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />RFCE E' <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />V/ <br />WELL CONSTRUCTION <br />MAR <br />Drilling Method <br />Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />3 ' <br />Proposed Well <br />Depth 30I max Excavation 8 in diameter Open Bottom Gravel Pack/Gravel <br />Siz NUJ met' <br />Well Casing <br />_ft <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel <br />,4 <br />y�cgCN� IRpNMECO(/ <br />Other H DER4 N <br />Grout Seal <br />Depth 30 ft X Neat Cement (94 lb bag/5-10 gal water) Sand Cement <br />sack mix17 ga I <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped X Free Fall Other Retardant / Accelerator (name) <br />3EDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />n 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 />,NIININICNI 24 1101 R kDVAVCE NO'lICE RFQCIRED FOR INSPEC"IIONS - PI.[.: %SLC -SLI -(209) 953-7697 <br />/ %DEPARTMENT USE ONLY <br />Application Accepted By l- v Date 3Po-P-7 Area 31 W4+1 feet-, Employee ID# �7 <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date n WAIVER Received <br />Soil Boring Inspection By Date ?.y Ig r f—w2"1Constructed Well Depth ft <br />COMMENTS �re.,-e D,Vv. e `e � i -T Pb*lr- •F'OP iF of rrojrlG4wct}'er IS <br />Y <br />T <br />PE <br />Codes <br />SC Received Check#/ <br />Info B Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />S rvice Re uest <br />43 is <br />1670 'semAlocq <br />I 1, <br />EHDO43-06 10/25/2021 Page 1 oft Well / Pump Permit <br />