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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 />NON-REFUNDABLE PERMIT h CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS _01! � O A �+wl CITY/ZIP Manteca <br />CROSS STREI <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />Htf PD'}- — <br />Chick-fil-A, Inc. <br />APN 24143031 <br />15635 Alton Parkway, Suite 350 <br />Gile Engineering Associates (Consultant) <br />PARCEL SIZE j' LAND USE APPLICATION # <br />PHONE (714) 595-6463 <br />CITY/STATE/ZIP Irvine, CA 92618 <br />PHONE (714) 279-0817 <br />CONTRACTOR ADDRESS 1965 N. Main Street CITY/STATE/ZIP Orange, CA 92865 <br />SUBCONTRACTOR Cal-Nev Geo Exploration PHONE (916) 778-0089 <br />SUBCONTRACTOR ADDRESS 1079 Sunrise Ave., Suite B-339 CITY/STATE/ZIP Roseville, CA 95661 <br />LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 1039188 EXPIRATION DATE 0'55/31/2024 <br />DoMEsnc WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) L Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring X 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 />❑ Monitoring Wells) # of wells X Soil Boring(s) 4 # of borings & Geotechnical 4# of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair Pq yA,.c <br />❑ New Pump ❑_Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION — %.' c I <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 15 to 50 ft Excavation 6 -inch in diameter Open Bottom Gravel Pack/Gravel Size di rte <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft SAN <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel El Plastic Ll Stainless Steel ❑ Ot rE JGAQVI <br />Grout Seal Depth 0 - 50 ft X Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement �TrNk <br />❑ Bentonite(20%solids) X Other Cement Slurry RT <br />Grout Placement Method ❑ Pumped X 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 />MWBIUNI 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 Boring Inspection B� / N_ <br />COMMENTS —rem ►2 b- )se <br />DEPARTMENT USE ONLY Yr, <br />Date g_111A'? Area 3 C;�tEmployeelD# <br />Date ❑ SPECIAL Well Permit <br />nate ❑ WAIVER Received <br />Constructed Well Depth <br />m <br />m <br />D <br />0 <br />O <br />m <br />m <br />Cn <br />PE <br />Codes <br />Sc Received <br />Info B <br />Check#/ <br />Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Re uest # <br />37a <br />12.2 <br />EHDO43-06 04/07/2022 Pa_, 1 42 Weil / Pomp Permit <br />IT <br />D <br />Ty <br />T <br />