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i <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT <br />JOB ADDRESS 1009 S Airport Way <br />CROSS STREET Wawona Street <br />OWNER NAME Irene Leandro <br />OWNER ADDRESS 1009 S AirportWay <br />CONTRACTOR Korbmacher Engineering <br />CONTRACTOR ADDRESS 480 Preston Court, Suite B <br />SUBCONTRACTOR California Geotech <br />SUBCONTRACTOR ADDRESS 6886 Village Parkway <br />(:ALL <br />ybS-fb!J/ FOR INSPECTIONS tAPIKtb 7 YEAR FROM DATE ISSUED <br />APN 241-310-380-000 <br />LICENSE x C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/ZIP Manteca, CA 95337 <br />PARCEL SIZE la?' v LAND USE APPLICATION # <br />PHONE <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 />NUMBER 812382 EXPIRATION DATE 9/30/22 <br />DOMESTIC WELL SAMPLING: [--General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392)1 Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ® Soil Sampling/Characterization <br />0 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 ® Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />#ofb <br />RFc� E� <br />WELL CONSTRUCTION - v <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary N Auger ❑ Cable Tool ❑ Push Point ❑ Other AU <br />Proposed Well Depth 20 ft Excavation 4-6 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Siz in dean <br />th — <br />Well Casing Diameterror Casing iiThickness/Gauge/ASTM ScheConductor Casing Do Steel ❑ Plastic ❑ Stainless Steel ❑ tAy[ V/CCN i CG <br />U <br />Grout Seal Depth Full Depth ft E Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mi Q�?pt <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped 9 Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />3EDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP D 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 />DEPARTMENT USE ONLY ,,✓1 j/�� <br />Application Accepted By �%� Z = Date i; 3 �02 Area �'✓�pyylle[ln Employee ID# f't S <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Dateaw WAIVER Received <br />Soil Boring InspectionByDate V 1l� �Z Constructed Well Depth ft <br />COMMENTS TrCW,e io lJ vte[J if cfbur,rJvJGI}B+' is eilcoun�.eyed <br />W <br />M <br />D <br />0 <br />0 <br />M <br />M <br />N <br />r <br />PE SC Received Check#/ Amount Date Permit/ Invoice # <br />Codes Info B Cash Remitted Service Re uest # <br />Well ID# <br />g3 <br />EHD043-06 04/07/2022 �Page I of 2 l�9ol / s78 <br />Well / Pump Permit <br />