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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 UALL LUy y53 -/by/ FOR INSPECTIONS I=AI'IKtb 7 YEAR FROM UATE ISSUED <br />JOB ADDRESS 4 Atrpof CITY/ZIP Manteca, CA 95337 <br />CROSS STREET Wawona Road <br />t APN neer .2 a a) OD1V PARCEL SIZE • LAND USE APPLICATION # <br />OWNER NAME City of Manteca, Contact: Greg Showerman <br />OWNER ADDRESS 1001 W. Center Street <br />CONTRACTOR Korbmacher Engineering, Inc. <br />CONTRACTOR ADDRESS 480 Preston Court, Suite B <br />SUBCONTRACTOR California Geotech <br />SUBCONTRACTOR ADDRESS 6886 Village Parkway <br />PHONE 209-456-8431 <br />CITY/STATE/ZIP Manteca, CA 95337 <br />PHONE 925-454-9033 <br />CITY/STATE/ZIP Livermore, CA 94551 <br />PHONE 831-634-1964 <br />CITY/STATE/ZIP Dublin, California 94568 <br />LICENSE K C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 812382 EXPIRATION DATE 9/30/22 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) 11 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ® 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 />SC Received <br />Info B <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings gl Geotechnical 1 <br /># of borings A �� <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />:ct <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />AU(� IG <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point 11 Other <br />3 <br />Proposed Well Depth 20 ft Excavation 4-6 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br />Size '4/V i <br />11Conductor Casing in diameter / Conductor Casing Depth ft <br />F/Fq RO U At <br />H DF MF <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel <br />❑ Other <br />Grout Seal Depth Full Depth ft )1 Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement <br />sack mix/7 gal wate , <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped %1 Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: 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 Bodng Inspection By <br />COMMENTS �j GW1 /e <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />i Date <br />Area S h fe<6% Employee ID#_ <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />T <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ Amount Permit/ <br />Cash Remitted Date a Re uest # Invoice # Well ID# <br />EHDO43-06 04/07/2022 n Page I of 2 Well / Pump Permit <br />T <br />