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WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 196s EAST HAMILTON AVENUE-STOCKTON CA 95205-(209)468-420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED z Joa ADDRESS �Q;"W Lathrop Rd CTTY/ap Manteca 195336 D CROSS STREET Sherwood Ave APN 197-020-} ()<� PARCEL SIZE 0.34 scree LANG USE APPUCAl10N i 0 /� � p A OWNER NAME ra•^v.�.woe r�1 d AP- ✓UP a/W-'•..� PHONE_(299rISGa000 a OWNER ADDRESS w=jm-:nor,t&et PO_�, MGIn4LS4, CITY/STATFIZIP Manteca/CA/95337 CONTRACTOR Taber Drilling PHONE 1(916)371-8234 CONTRACTOR ADDRE33 536 Gdveeton St CTTYISTATEMP_West Sacramento/CA/95691 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDREss CTTY/STATEMP LICENSE E C-57 ❑C-61 J D-09 E Other NUMBER 969927 EMRATION DATE 0 22 912 0 2 0 DoMEenc WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)D Arsenic(4393) INTENDED USE ❑DOmestiaPrivate C InigationlAgricuitural ❑Industrial G Water Quality Monitoring X Soil Sarnpling/Characterization ❑Pudic Water System R Atrsrnrt Irom Owner. Water System Nemo Co bW Nems a Ptane tkmibm TYPE OF WORK C New Walt ❑Replacement Well ❑Well WterstiorJModi9catlon ❑Other ❑Monitoring Well(s) #of wells I-Sod Boring(s) a a Do npa A Geotechnical 1 eor bortnps ❑Out-Of-Swvloe Well D Out-O( wr -Service Well Renal 11vroction Cross-CorRepair A�A� --New P C Pu Replacement it P Re n Raise Wed Casl 4s �® WELL CONsTgucnoN Drilling Method X Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tod o Push Point ❑ Other 44 ` Proposed Well Depth 50 It Excavation 6 in dismater U Open Bottom Gravel PackJGravel Size 1 p2*pier 2019 U Conductor Casing in diameter / Conductor Gasinp Depth tt .n_�UV ��}F" Well Casing Diameter_in Thickness/Gauge/ASTM Schad C Steel C Plastic C Stainless Steel ❑Other H F��R Grout Seal Depth entire it 9 Neat Cement(94 lb bagl5-10 gal water) C Send Cement sack mix17 g NMENT UN�' ❑Bentori to(20%solids) n Other pgRTMFNT Grout Placement Method 10 Pumped ❑Free Fall ❑Other C Retardant/Accelerator(name) PEDESTAL Installed By C Driller ❑Pump Contractor Other C Concrete Pedestal ODimensions:Width tt Length it Thick in C Christy Box C Stove Pipe PUMP 0 Submersible n Turbine ❑Other HP Pump Set It Standing Water Level R I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATIO WS. MIN URA ICE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)46 7694 SIGNED Tn. V I V DATE lot Iq I TUT r—jupRTMENT USIJ ON yn[�fJ�``/'� Application Accepted By Dete l Are Employee Grout Inspection By,V'21_ r ate "7 r ❑ SPECIAL W911 Permit Punts Inspection By Date ❑ WAIVER Received SON Boring Inspection By Date Constructed Well Depth It COMMENTS PE SC Received Amount Date Service Invoice# Well IDN Codes Into -Cash Remitted Service R uest# EHO 43-06 revisal V14/18 WELL/PUMP PERMrT