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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East' HAzEt-roN AVENUE - SrocicroN CA 95205-6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />119 Almond Ave. CrrWbe Manteca/CA/95337 <br />Juaguin St. ApN217-040-060-000 PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />Kim Cimoli PHONE 209-839-7475 <br />218 Tiffany Cir CrrY/STATE/Zte Ripon CA, • 95366 <br />California Geotech PHONE 831-634-1964 <br />CONTRACTOR ADDRESS 6886 Village Pkwy CirdSTATE/zip Dublin/CA/94568 <br />SuecoNTRAcroe/CoNsuLTANT Calgeotech Engineering Consultants, Inc. PHONE 925-551-0774 <br />3329 Pine Valley Rd. San Ramon/CA/94583 SUBCONTRACTOPJCONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 E C-61 51D-09 - Other <br />NUMBER 812382 EXPIRATION DATE 30 2_o <br />BILLING PARTY: LI OWNER _1 CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ,1 General MineraVColiform Bacteria (4391) C Dibromochloropropane (4392) 9 Arsenic (4393) <br />INTENDED USE Li Domestic/Private LI Irrigation/Agricultural n Industrial C Water Quality Monitoring 3 Soil Sampling/Characterization <br />L] Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK LI New Well C Replacement Well Well Alteration/Modification 0 Other <br />(-1 Monitoring Well(s) # of wells # of borings Soil Boring(s) Geotechnical 1 <br /> # of borings <br />0 Out-Of-Service Well Li Out-Of-Service Well Renewal <br />0 New Pump C Pump Replacement C Pump Repair o <br />O. Cross-Connection Repair <br />Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 51 Mud Rotary U Air Rotary C Auger U Cable Tool 0 Push Point 0 Other solid stem <br />Proposed Well Depth 20 ft Excavation 4 inchin diameter 0 Open Bottom 7 Gravel Pack/Gravel Size in diameter <br />El Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTIV1Sched C Steel 0 Plastic C Stainless Steel El Other <br />Grout Seal Depth ft fT Neat Cement (4 lb bag/5-10 gal water) U Sand Cement sack mixf7 gal water <br />5 Bentonite (20% solids) 0 Other <br />Grout Placement Method 2 Pumped 07 Free Fall 0 Other IL- Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller E Pump Contractor 0 Other <br />Concrete Pedestal t IDimensions: Width ft Length ft Thick in 2 Christy Box 0 Stove Pipe <br />PUMP Submersible0 Turbine 0 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 WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSA 10 WS. <br />Dall%) • <br />1 S4 <br />tiE-,<VVL_ <br />I I I :SSMICIONI 3.11S SIGNED , <br />11,91V,ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE eteail 4.- DATE 3 /1-0 24 <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By 1/.----Z...— Date 3 /allidi /Area 3 / ei 9 Employee ID# b <br />Grout Inspection By A . ‘5------- Date 51'il 2-1 E SPECIAL Well Permit <br /> <br />Pump Inspection By Date H WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS It ern in if -to -,,.D 6,1.ec-J i r. to,fr ;xlvv /ric--- Lc t.;11,;5;-01-ered J <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />LI 3 7L) 1S-3 dig V.; C.,..— 4 Lgs--, 311-Sim moit-I iu137 <br />EHD 43-06 6/11/2019 <br /> # /22.,a3 /2., WELL /PUMP PERMIT <br />ft