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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 />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS 2125 Daniels St CITY/ZIP Manteca/95336 <br />CROSS STREET Airport Way APN 24131086 PARCEL SIZE 1.75 acres LAND USE APPLICATION # <br />OWNER NAME Jamail Kamboj 8 Jasbir Singh PHONE 209-858-2666 <br />OWNER ADDRESS 147 Lathrop Road - (" I �j IL e' t O f ? E CITY/STATE/ZIP Manteca/CA/95330 <br />CONTRACTOR West Coast Exploration Inc PHONE 209-985-7541 <br />CONTRACTOR ADDRESS P.O. Box 133 CITY/STATE/ZIP Escalon/CA/95320 <br />SUBCONTRACTOR CTE CAL Inc PHONE 209-534-1799 <br />SUBCONTRACTOR ADDRESS 4230 Kiernan Ave Ste 150 CITYISTATE/ZIP Modesto/CA/95356 <br />LICENSE X C-57 C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 1/31/2024 <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 New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of cof1ngs X Geotechnical 3 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION SAN <br />Drilling Method Mud Rotary Air Rotary Auger : Cable Tool Push Point Other <br />Proposed Well Depth 20 ft Excavation 4 in diameter Open Bottom Gravel Pack/Gravel Size inh <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth � O ft X Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method , Pumped X Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <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 It <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 />11I:N0101 2.1 IIULR ADNANCE NU'( ICF. REQUIRED FUR INSPECTIONS - PLEASE CAL.I. (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By�'� Date u7r.[ Area�^ j� r t (employee IN Jam' <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Pt Z OZ 7 Z -Constructed W II Depth ft <br />COMMENTS d/(�^ i <br />Ec MEN r <br />EI vED <br />PR 0 12022 <br />AQU/N C <br />RON1 OUNTy <br />DEPARTMENT <br />EHD041-0610/25/2021 // /��Pa 1 <br />f2 3777Well l Pump Pmmit <br />� <br />r . <br />A <br />EHD041-0610/25/2021 // /��Pa 1 <br />f2 3777Well l Pump Pmmit <br />