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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 />NLJN-KEFUNDABLE PERMIT <br />JOB ADDRESS 19051 S. McKinley Ave. <br />CROSS STREET N. of Hwy 120 <br />OWNER NAME Komal Atwal <br />CALL (LUU) UbJ-[b9[ FOR INSPECTIONS EXPIRE5 1 YEAR FROM DATE ISSUED <br />CITY/ZIP Manteca 95337 <br />APN 241-40-018 PARCEL SIZE 14.11 LAND USE APPLICATION # <br />PHONE 209-321-0826 <br />OWNER ADDRESS 3701 W. Linne Rd. <br />CONTRACTOR Hennings Bros. Drilling Co., Inc. <br />CONTRACTOR ADDRESS 1930 Ladd Rd. <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 ❑ C-61 ❑ D-09 II Other <br />CITY/STATE/ZIP Tracy, CA 95304 <br />PHONE 209-545-1185 <br />CITY/STATE/ZIP Modesto, CA 95356 <br />CITY/STATE/ZIP <br />NUMBER 290813 <br />PHONE <br />EXPIRATION DATE 5-31-23 <br />DOMESTIC WELL SAMPLING: CI General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private I I Irrigation/Agricultural i I Industrial I i Water Quality Monitoring I1 Soil Sampling/Characterization <br />ElPublic Water System U" <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 of bfdngs <br />X Out -Of -Service Well 10° Steel Out -Of -Service Well Renewal Cross -Connection Repair ° <br />I I New Pump ❑ Pum Re lacement Li Pum Re air Raise Well CasingSOA v` <br />WELL CONSTRUCTION H� 0 <br />0NA1fiIVTqIV T, <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary I Auger C Cable Tool I Push Point Other T <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom CI Gravel Pack/Gravel Size in di eter <br />I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel i Plastic I I Stainless Steel Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag15-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall Other Retardant / Accelerator (name) <br />3EDESTAL Installed By ❑ Driller (I Pump Contractor Other <br />Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n Christy Box ❑ Stove Pipe <br />PUMP I I 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 <br />Application Accepted By �i ` L Date /.+7 .� r� Area 3 / Employee ID# <br />Grout Inspection By/`� Date �' Z Cl SPECIAL Well Permit <br />Pump Inspection By Date I I WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMEI)ITS re11A4,17�� !(.. O.iT � " S('fV!tf fD! � li(�7ri rl)f T�,Y�Cj✓� rn(Y L4'l� �! j/le <br />Ln <br />M <br />0 <br />0 <br />0 <br />M <br />M <br />C2 <br />PE <br />Codes <br />SC Received Che <br />Info <br />Amount Dat Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />F.1ID043-06 10/25/2021 r.p 1 42 Wc[I / Pump Permit <br />