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I WELL/PUMP PERMIT 2353 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 17846 Glenwood Rd. CITYIZIP Manteca/95336 CROSS STREET Kimberly Dr. APN 208-35-011 PARCEL SIZE 0.34 LAND USE APPLICATION # OWNER NAME David Russell PHONE 650-274-4324 OWNER ADDRESS SAME CITY/STATE/ZIP CONTRACTOR Delta Pump Inc. PHONE 209-466-9625 CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIP Stockton/95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZIP LICENSE 1.1 C-57 X C-61 D-09 L -I Other NUMBER 1055434 EXPIRATION DATE 7/31 /2023 DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural -i Industrial _' Water Quality Monitoring ❑ Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK n New Well r° Replacement Well ❑ Well Alteration/Mod if cation I- Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings 1-1 Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal C Cross -Connection Repair p^ ❑ New Pump X Pump Replacement ❑ Pump Repair I Raise Well Casing"! WELL CONSTRUCTION C' Drilling Method a Mud Rotary Air Rotary I1 Auger I_ Cable Tool 11 Push Point _I Other !� Proposed Well Depth ft Excavation in diameter ❑ Open Bottom : 1 Gravel Pack/Gravel Size Wd meter 11 Conductor Casing in diameter / Conductor Casing Depth ft Sq Q ?Q Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 11 Steel C Plastic 1-1Stainless Steel OJGq Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) I Sand Cement Fglst$rj Ll Bentonite (20% solids) U Other Grout Placement Method - Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) N PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other C Concrete Pedestal Ll Dimensions: Width ft Length ft Thick �in - Christy Box :1 Stove Pipe PUMP Submersible, i Turbine 1 Other HP -_I_ Pump Set__6_Q_ ft Standing Water Leveler ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. MINIMUM 24 HOUR ADVANCE NOTWE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY Employee Area I �9C ID# I- Application Accepted By -� L-- Date Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS `��\ �(,� Q \.�?.�l�t�l� �( A �A k�e VO U(k-k /T O PE Codes SC ReceivedCheck# Info By- Cash Amount Remitted Date Permit/Invoice # Well ID# Service Request # 43ef 0�`:5 M e I^EPt. L43 [HD0d3-06!0/25/20'_1 four I o! ' Well I Pump Penmt