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1 WELL/PUMP PERMIT 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 4343 E. Mortensen Rd. CITY/ZIP Manteca 95337 m W. of Airport Way 40.42 D CROSS STREET p y APN241-20�-(004 PARCEL SIZE LAND USE APPLICATION# X OWNER NAME D & D Farms C 111 h1 &111,1 1 R PHONE 209-765-7565 y OWNER ADDRESS 28536 South Airport Way CITY/STATE/ZIP Manteca, CA 95337 I CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-1545-1185 CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto, CA 95356 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CrrY/STATE/ZIP LICENSE C-57 i i C-61 n D-09 q Other NUMBER 290813 EXPIRATION DATE 5-31-24 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial `7 Water Quality Monitoring fl Soil Sampling/Characterization A' Public Water System If different from Owner: Water System Name Contact Name or Phone Number CO TYPE Qe','VORK New Well Replacement Well Well Alteration/Modification E Other UFP _i Monitoring Well(s) #of wells r 1 Soil Boring(s) #of borings I Geotechnical rings ZZ Out-Of-Service Well Out Of-Service Well Renewal Cross-Connection Repair ENV 4 QrJ/ New Pum u Pum Replacement i Pum Repair a Raise Well CasingNE4� /BONN C° WELL CONSTRUCTION Reverse �Rrl, I- Drilling Method I' Mud Rotary n Air Rotary Auger ❑ Cable Tool ; Push Point 1 Other 'N 7 Proposed Well Depth 350 ft Excavation 26 in diameter D Open Bottom 0'.Gravel Pack/Gravel Size N0.6 in diameter L)/Conductor Casing �30 in diameter / Conductor Casing Depth J0 ft Well Casing Diameter 16 in Thickness/Gauge/ASTM Sched 1/4" ga XSteel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth 50 ft Neat Cement(94 Ib bag15-10 gal water) �N Sand Cement sack mix17 gal water Bentonite(20%solids) Other 30"x50' Cond. cemented-in 2 narts sand/l nart cement• Grout Placement Method N Pumped iJ Free Fall ❑ Other J Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller X Pump Contractor ❑ Other Concrete Pedestal❑Dimensions:Width ft Length ft Thick �in Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine �i Other HP Pump Set ft Standing Water Level 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 NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL,(209)953-7697 DEPARTMENT USE ONLY Application Accepted By G'�L L Date )'� �� '� Area $ Employee ID# AS Grout Inspection By �� Date On ?i L SPECIAL Well Permit Pump Inspection By Date _i WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS � re,M D h 1_' eco e rr AJ-7-aa . Sep ee4 U 0s re ►red f L PE SC Received Ch Amount Date Permit/ Invoice# Well ID# Codes Info B Remitted ervice Request# y369 �o qdD 12.132 NO t:ntn a3-0a 10/25/2021 Page 1 of 2 well i Pe„y,Pem,ir