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' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 985 W. LathropRd. Manteca, CA 95336 mq <br /> JOB ADDRESS CITYIZIP mD <br /> CROSS STREET Sher—/w.oyo�d P1 APN 19702072 PARCEL SIZE 14 LAND USE APPLICATION# b0 <br /> OWNER NAME `� ( / /Tr, � PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP - <br /> CONTRACTOR Klelnfelder PHONE 209.948.1345 <br /> CONTRACTOR ADDRESS 2001 Arch-Airport Road, Suite 100 CITYISTATERIP Stockton, CA 95206 <br /> SUBCONTRACTOR V&W Drilling, Inc. PHONE 209.469.7700 <br /> SUBCONTRACTOR ADDRESS 1133 Blackhurst Dr CITYISTATEfZIP Galt, CA 95632 <br /> LICENSE EZC-57 U C-61 0 D-09 0 Other NUMeFR 720909 EXPIRATIONDATE 04�3O�2020 <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)7 Dibromochloropropane(4392)71 Arsenic(4393) <br /> INTENDED USE L DomesticlPrivate U Irdgation/Agricultural IJ Industrial 0 Water Quality Monitoring X Soil Sampling/Characterization <br /> F Public Water System <br /> 0differenl from Oymer. Waler Syslom Noma Contact Name or Phone Number <br /> TYPE Or WORK C New Well 7 Replacement Well 0 Well AlterationlModilication D Other <br /> C Monitoring Wallis) #of wells 0 Soil Boring(s) ft of borings tg Geotechnical 1 0 or borings <br /> L Out-Of-Service Well LJ Out-Of-Service Well Renewal U Cross-Connection Repair <br /> F New Pump n Pump Replacement F Pump Repair -1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r Mud Rotary n Air Rotary rX Auger r Cable Tool n Push Point f Other <br /> Proposed Well Depth 2 0 it Excavation 6 In diameter ❑Open Bottom ❑Gravel Pack/Gravel Size In diameter <br /> ❑Conductor Casing In diameter / Conductor Casing Depth it <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched I i Steel I I Plastic i Stainless Steel i I Other <br /> Grout Seal Depth 2 0 ft X Neal Cement(94 M bag/540 gal water) IT Sand Coment .sack m1xf7 gal water <br /> U Benlonite(20%solids) U Other <br /> Grout Placement Method n Pumped IXFree Fall n Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller U Pump Contractor u Other <br /> C Concrete Pedestal(Dimension:Width it Length ft Thick In 7 Christy Box 0 Stove Pipe <br /> Puµp L Submersible❑Turbine �2 Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IN UM 48� ADVANCE NOTICE REQUIRED FOR INSPECT NIS-PLEASE CALL(209)9 3-7697 <br /> SIGNED— V TITLE 1-I� l-�EO1 C'C?(0T DATE RjILLjjYt <br /> J-4 yll® <br /> Fo <br /> NiN C <br /> qRT glNry <br /> MENT <br /> --TT-TT-- <br /> EP T M E N T U7 E 0 li <br /> Application Accepted By Date Area / ' Employee iD# <br /> Grout Inspection By Dale EJSPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info ash emitted Date ervicepQ st H Invoice# We11 ID# <br /> i •J <br /> EHD 4306 revised 4/74116 � �,/������ WELL fPUA1P PERMIT <br />