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1 r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1140 Bessemer AvenueCITy/Zlp Manteca/95337 In <br /> CROSS STREET Industrial Park Drive APN dQ11 I q Ori 9 PARCEL SIZE _LAND USE APPLICATION If A <br /> m <br /> OWNER NAME RoofScr•een Manufacturine\California PowderWorks-Ryan Bruce PHONE (831)421-9230x]10 N <br /> OWNER ADDRESS 347 Coral Sweet CITY/STATEIZIP Santa Cruz,CA 95060 a <br /> c <br /> CONTRACTOR V&W Drilling-Contact:Karli Stroing PHONE 209.981.7755 <br /> i9 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive CrTY/STATE/ZIP Galt,CA 95632 <br /> SUBCONTRACTOR/CONSULTANT Condor Earth-PM:Chad BOrean,Cell:209.601.1430 PHONE 209.234.0518 D <br /> ro <br /> 0 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 188 Frank West Circle,Suite I CITY/STATErZJP Stockton,CA 95632 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 720904 EXPIRATION DATE 04/30/2022 <br /> 0 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR{CChSI:iIB.,THNT G <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) w <br /> w <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings X Geotechnical 2 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 20 It Excavation 4 1/2 in diameter Open Bottom Gravel Pack/Gravei Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth full depth It X Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It 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 /> MlNlylil �IB HOU E1 E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED (/ TITLE Project Coordinator DATE 11/01/20 <br /> Coffert C) r �VFD <br /> on Pprmf}. s ylJ4 20 <br /> ?D <br /> bQe"o �pc�U I n <br /> /N c <br /> novae V E�� o ENOUNTy <br /> t"_ RTMENT <br /> / DEPARTMENT USE ONLY <br /> Application Accepted By `� Date 0 O Q Areas � �� Employee ID#DA <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date O Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount 'Permit/ <br /> Codes Info Cash Re—iff-l Date ce Requ`est invoice# Well ID# <br /> +41 CIS, 00'-11�t I <br /> EHD 43-06 611112019 /J_ � /�����0 WELL(PUMP PERMIT <br />