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r <br />WELL/PUMP PERMIT " <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />f1U11-RtFUNUAtrLt PERMIT (;ALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 6793 E. Woodward Avenue Cm/zIP Manteca, CA 95337 <br />CROSS STREET Lakeside Avenue APN 224-021-15 PARCELSIZE+"/-20. 12 LAND USE APPLICATION# <br />OWNER NAME _Atherton Woodward Partners, LLC - Contact: Albert Boyce PHONE 209.479.2896 <br />OWNER ADDRESS 1309 Mirassou Drive liPID /� / I CITY/STATE/ZIP Manteca, CA 9533 <br />CONTRACTOR West Coast Exploration PHONE 209.838.1723 <br />CONTRACTOR ADDRESS P.O. Box 133 CIN/STATE/ZJP Escalon, CA 95320 <br />SUBCONTRACTOR PHONE <br />ADDRESS <br />CITY/STATE/ZJP <br />LICENSE X C-57 i C-61 D-09 i Other NUMBER C-57-870761 EXPIRATION DA <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) . Arsenic (4393) <br />NTENDED USE i Domestic/Private Irrigation/Agricultural 1 Industrial i Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells I Soil Boring(s) # of borings X Geotechnical 4 <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 5 to 20 ft Excavation 4 1/2 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft X Neat Cement (94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) i Other <br />Grout Placement Method Pumped X Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor -- Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box i Stove Pipe <br />PUMP Submersible Turbine 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 />MINIM OUjt�A VANCE N ICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Owner/Operator DATE 09/07/2018 <br />DEP RTMENT U E N Y <br />Application Accepted By Date Area Employee ID# <br />Grout Inspection By Date q ECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />I y <br />H <br />D <br />0 <br />z <br />m <br />N <br />7 2018 <br />IN COUNTY <br />EHD 43-08 revised 4/14/18 WELL /PUMP PERMIT <br />