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I WELL/PUMP PERMIT 2395 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 488-3420 IVVIV-r[CrUr4UA0Lt r-tKMl1 ;,ALL IZIUVI VO4-/by/ FOR INSPECTIONS EXPIRE5 1 YEAR FROM DATE ISSUED JOB ADDRESS 6590 Lathrop Rd. CITY/ZIP Manteca/95336 CROSS STREETS. Frontage Rd. APN 218-040-01 PARCEL SIZE 0.98 LAND USE APPLICATION # OWNER NAME _Me Costa PHONE 209-647-0188 OWNER ADDRESS Same as Above CITY/STATE/ZIP CONTRACTOR Delta Pump Inc. PHONE -2046&9625 CONTRACTOR ADDRESS 646S. CallfOrnla St. CITY/STATE/Z P. StocktON95203 SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE ❑ C-57 X C-61 0 D-09 ❑ Other PHONE CITY/STATE/ZIP NUMBER 1055434 ExPIRATION DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner. Water System Name Contact Name or Phone Number P% _ TYPE OF WORN ❑ New Well ❑ Replacement Well 0 Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells 0 Soil Boring(s) a of borings 0 Geotechnical 0 Out -Of -Service Well C Out -Of -Service Well Renewal 0 Cross -Connection Repair ❑ New Pump X Pump Replacement E Pump Repair 0 Raise Well Casino a or Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger El Cable Tool 0 Push Point C Other u E JOq Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size' (NMI@I t Ty 0 Conductor Casing in diameter / Conductor Casing Depth ft Pq R rM, Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other T Grout Seal Depth ft 0 Neat Cement (94 lb ba96-10 gal water) 0 Sand Cement sack r*x/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped D Free Fall 0 Other 0 Retardant /Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other ❑ Concrete Pedestal ODlmensions: Width ft Length ft Thick lin C Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine 0 Other HP Pum Set p 60 _ft Standing Water Level JD_ ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CPS 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. MINI\It \I 24 IIOI R \1)\ .\\('t:.%OI I('1: ItI'-Q1 IRED FOIL INSI'I:(-[ IONS- I'1•F.:\fit: (':\I.I. (2119)4:3-7697 Application Accepted By -- Grout Inspection Pump Inspection By Soil Boring Inspection By COMMENTS DEPARTMENT USE ONLY Date % ' r Area ! �� Employee ID# Date 0 SPECIAL Well Permit Date�10\5.,0`�\" 0 WAIVER Received Date Constructed Well Depth ft Page I of 2 Well i Pump Pernt . Page I of 2 Well i Pump Pernt