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l WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />CALL (2U9) 9b:3-tb91 FOR INSPECTIONS <br />EXPIKE5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />1280 Cottage <br />Court CITY/ZIP+Manteca/95336 <br />CROSS STREET <br />Cottage Ave. <br />APN 20826022 PARCEL SIZE rl <br />LAND USE APPLICATION # <br />OWNER NAME <br />David Spiegel <br />PHONE 818-404-1443 <br />OWNER ADDRESS <br />23289 Ventura <br />Blvd., CITY/STATEIZIP <br />Woodland Hills, CA 91364 <br />CONTRACTOR California Geotech Drillin <br />PHONE 831-664-6268 <br />CONTRACTOR ADDRESS 6886 Village Pkwy CITYISTATE/ZIP Dublin/ CA/ 94568 <br />SUBCONTRACTOR Manny Saleminik/Calgeotech Engineering PHONE 925-548-0111 <br />SUBCONTRACTOR ADDRESS 3329 Pine Valley Rd. CITY/STATE/ZIP San Ramon, CA 94583 <br />LICENSE x C-57 C-61 ❑ D-09 ❑ Other NUMBER 812382 EXPIRATION DATE 9/30/2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) ! Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring R 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 borings 10 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 <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary El Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth /S o?Q ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <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—/ C -al a ft a Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal DDimensions: 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS �f ervt he. <br />DEPARTMENT USE ONLY <br />Date .r�9 <br />Date <br />Date <br />�— Date r �� <br />Area 31"4✓1 -1e<k Employee ID# A <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />m <br />D <br />0 <br />0 <br />m <br />m <br />U) <br />PE <br />Codes <br />SC Received Check#/ <br />Info B ash <br />Amount Permit/ <br />Remitted Date Servic Request # Invoice # Well ID# <br />4 37(9 <br />► So <br />60 <br />EHDO43-0604/072022 Page I oft <br />/�-z71 `377 c6 <br />/13Zs/2-0q <br />Well / Pump Permit <br />