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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 t;ALL ZU`.1 y53-!bUI FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1014 S. Airport Way CITYIZIP Manteca, CA 95337 <br />CROSS STREET Wawona Street APN 222-19-051 PARCEL SIZE � • O 7' LAND USE APPLICATION # <br />OWNER NAME Robinson Oil Corporation PHONE 408-327-4325 <br />OWNER ADDRESS 955 Martin Avenue CITY/STATE/ZIP Santa Clara, CA 95050 <br />CONTRACTOR Korbmacher Engineering <br />CONTRACTOR ADDRESS 480 Preston Court, Suite B <br />SUBCONTRACTOR California Geotech <br />SUBCONTRACTOR ADDRESS 6886 Village Parkway <br />LICENSE k] C-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE 925454-9033 <br />CITYISTATEIZIp Livermore, CA 94551 <br />PHONE 831-634-1964 <br />Cm/STATE/Zlp Dublin, California 94568 //''�� <br />NUMBER 812382 EXPIRATIONDATEV t'�� <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) - Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring U, Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Plane Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well 0 Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings A l Geotechnical -2 5 <br />! Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />L New rump a rump Keplacement a rump Kepalr u Kaise vveln uasmg <br />WELL CONSTRUCTION <br />Drilling Method F Mud Rotary -1 Air Rotary 0 Auger i ! Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 20'-25' ft Excavation 4"-�B" in diameter F 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 Full Dept, ft Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />3EDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />PAYMENI <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick RECEIVED <br />n ❑ Christy Box ❑ Stove Pipe <br />Pump ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Wa v ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the followin items: GPS <br />S(,N JO IN COUNTY <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existin �lertQtuctures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. -"dors ' mestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINIMUNT 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC'T'IONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By L' L Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By , F ' Date 1, Z. Z <br />COMMENTS <br />Area /)1(. Employee ID# <br />❑ SPECIAL Well Permit <br />(i WAIVER Received <br />Constructed Well Depth ft <br />m <br />D <br />v <br />v <br />A <br />m <br />U) <br />PE <br />Codes <br />4 7,2 <br />SC Received Check#/ <br />Info B Ca h <br />5D <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Re ue t # <br />rr011 L2 <br />EH1304306 IWi072022I tJ � 1 S R ft . 3 y /�/ n Yee 1 of 2 Well ! 11—p Permit <br />