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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCK rON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS 1601 S. Main St. <br />GALL (/UV) UO i -10U 1 FUH INSNLG I IUNS r—ArIRCJ I r tAK rrcUm URIC 1JJUCU <br />CITY/ZIP Manteca, 95337 <br />CROSS STREET Atherton Dr. APN 224-02-147 <br />OWNER NAME groGGylln;ti'LI1�% PGr}re�s�hip <br />OWNER ADDRESS Sq51 L • i"S 'AVP <br />CONTRACTOR Technicon Engineering Services, Inc. <br />CONTRACTOR ADDRESS 4539 N. Brawley Ave. Suite 108 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE , C-57 ❑ C-61 0 D-09 0 Other <br />PARCEL SIZE LAND USE APPLICATION #, <br />PHONE rr'' <br />CITY/STATE/ZIP iia n fe [e, 16 33 7 <br />PHONE 559-276-9311 <br />CITY/STATE/ZIP Fresno, CA 93722 <br />CITY/STATE/ZIP <br />NUMBER 767888 <br />PHONE <br />EXPIRATION DATE m/^ I <br />DOMESTIC WELL SAMPLING: ; General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) : Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 95 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 0 Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells R Soil Boring(s) 5 # of borings Geotechnical 5 of <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />n New PumD ❑ PumD Replacement O Pump Repair ❑ Raise Well Casing <br />[r <br />-.I <br />m <br />D <br />O <br />O <br />A <br />m <br />Ca <br />to <br />WELL CONSTRUCTION.. [ <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary M Auger 0 Cable Tool 0 Push Point Ll Other AN J <br />Proposed Well Depth 0-501 ft Excavation 4° in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size N / 'C <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft oEp FIV <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel ❑ Other gRTn1 <br />Grout Seal Depth O- SO ft ;(Neat Cement (94/b bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped X Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor C Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ftThick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersibleu Turbine 0 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 />MiI 41MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 074Q Area 3 kn4CceA Employee ID# All <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date Q WAIVER Received <br />Soil Boring Inspection By Date ?A'D'Z.. Constructed Well Depth <br />COMMENTS Tyrmle D[012- a Z1Se 1 deeper tharl `0 Aegf or a r 6/vA 4CT: 1S PNLOUh of 06 <br />PE Sc ReceivedChe <br />Codes Info <br />Amount ate Permit/ Invoice # Well ID# <br />Remitted ervice Request # <br />EHDO43-06 04/07/2022 Page I of 2 Well / Pump Permit <br />