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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOBADDRESS 0 S Tinnin Rd <br />CALL ZU9 953-T69/ FOR INSPECTIONS ItArlttt, 7 TEAR FROM DATE ISSUED <br />CITY/ZIP Manteca, CA 95337 <br />CROSS STREET Sedan Ave APN 4&41- dd I OV T/ PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME San Joaquin Area Flood Control Agency PHONE 209-937-7900 <br />OWNER ADDRESS Stewart -Eberhardt Building, 22 E Weber Ave, 4301 CITYISTATE/ZIP Stockton, CA 95202 <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />ENGEO <br />17278 Golden Valley Parkway <br />GEO-Ex Subsurface Exploration <br />SUBCONTRACTOR ADDRESS 1510 Madera Drive <br />LICENSE X C-57 1.1 C-61 Ci D-09 L Other <br />NUMBER <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP <br />9S4267 <br />PHONE 925-866-9000 <br />Lathrop, CA 95330 <br />PHONE <br />Dixon, CA 95620 <br />EXPIRATION DATE 07/31/2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private L Irrigation/Agricultural [ i Industrial L Water Quality Monitoring X Soil Sampling/Characterization <br />[7 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well f] Well Alteration/Modification <br />❑ Other <br />❑ Monitoring Well(s) # of wells L Soil Boring(s) 1 # of <br />borings X Geotechnical 5 # of borings <br />l7 Out -Of -Service Well I Out -Of -Service Well Renewal <br />L Cross -Connection Repair <br />L New Pum L Pump Replacement L Pump Repair <br />L Raise Well Casing <br />WELL CONSTRUCTION <br />Cone Penetration Test <br />Drilling Method 9 Mud Rotary ElAir Rotary 11 Auger I Cable Tool [I Push Point <br />X Other <br />Proposed Well Depth 100 ft Excavation 4/2 in diameter LI Open Bottom 1] Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth <br />ft pAYLI1�VT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched E, Steel <br />L Plastic n Stainless Step` <br />Grout Seal Depth 100 ft X Neat Cement (94 /b bag/5-10 gal water) <br />L Sand Cement RECEIVMix/7 gal water <br />❑ Bentonite (20% solids) L Other <br />Grout Placement Method L Pumped L Free Fall Other Tremae ❑ Retardant <br />/ Accelerator (name) APR 2 R 2n22 <br />PEDESTAL Installed By F. Driller P Pump Contractor P Other <br />L Concrete Pedestal LDimensions: Width ft Length ft Thick ENVIRONMENTft <br />�in F1 Christy Box L Stove Pipe 9 &AITH DEPORT042! <br />PUMP L Submersible Turbine L 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 />1tl\INII y1 24 110t R AD% A\('F 's01 R1�: Itt,QI IRlil) FUR I\S[,I-( 110\S - PI. LAS V ('AL1. (209) 953-7697 <br />j <br />DEPARTMENT USE ONLY f <br />Application Accepted By `=— F` 4 4 Date -7 a7 Area j ►� fe «+ Employee ID# <br />Grout Inspection By Date IE(ZZ - SPECIAL Well Permit <br />Pump Inspection By Date - WAIVER Received <br />Soil Boring Inspection By _ Date 7'Constructed Well Depth ft <br />COMMENTS �c%,��� S h,,;;r ✓n►r�;1"Ukk1 aS Pt.f SDe%.jCt rtechild(,1 $u:!VIA E'S)ie s loiiL <br />T <br />PE <br />Codes <br />SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Info BY. ash Remitted S rvice Re uest# <br />EHDO43-06 04/07/2022 Page I of 2 Well / Pump Permit <br />