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< e , <br />1 t r" W o0aw v-1 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />PIVIV-KtFUNUAtiLt YtKMI I <br />LALL(LUJ) Z003 -/0y/ FUK INSI'tG I IUNS <br />CAWIKCA"I T tAK t'KUM UA It ISSUtU <br />Jae ADDRESS <br />Woodward Avenue <br />CITY/ZIP <br />Manteca 95337 <br />CROSS STREET <br />E Atherton Or <br />APN NA PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME <br />City of Manteca <br />PHONE <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR <br />Blackburn Consulting <br />PHONE (916) 375-8706 <br />CONTRACTOR ADDRESS 2491 Boatman Avenue <br />CITY/STATEIZIP West Sacramento, CA, 95691 <br />SUBCONTRACTOR <br />Taber Drilling <br />PHONE (916) 371-8234 <br />SUBCONTRACTOR ADDRESS 536 Galveston St <br />CITYISTATE/ZIP West Sacramento, CA, 95691 <br />LICENSE x C-57 <br />_ C-61 i D-09 <br />Other NUMBER 969927 <br />EXPIRATION DATE 02/29/2020 <br />DOMESTIC WELL SAMPLING:. General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) _ Arsenic (4393) <br />NTENDED USE i Domestic/Private "i Irrigation/Agricultural l Industrial Water Quality Monitoring x Soil Sampling/Characterization <br />- I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK - New Well I Replacement Well f' Well Alteration/Modification I Other <br />i Monitoring Well(s) #of wells x Soil Boring(s) Ifof borings x Geotechnical 1 #of borings <br />I: Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New rump rump Kepiacemenc _ rump Kepalr Kalse vveu uasmg <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary x Auger Cable Tool -i Push Point , Other <br />Proposed Well Depth 5 It Excavation 4 in diameter - Open Bottom i i Gravel Pack/Gravel Size in diameter <br />i i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched - Steel I Plastic Stainless Steel I i Other <br />Grout Seal Depth ft x Neat Cement (94 Ib bag/5-10 gal water) i i 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 C Christy Box Stove Pipe <br />PUMP - Submersiblei Turbine ii Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 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 />UM 4 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE VP / Exploration Coordinator � � L... )DATE 02.06.2019 <br />D,jEPARTM ENT USE NLY <br />Application Accepted By Date w" <br />Grout Inspection By 77 Date <br />Pump Inspection By / Date- <br />Soil <br />ateSoil Boring Inspection By/Ner �t �t Z' Date 3� <br />COMMENTS <br />PA <br />M, ��'V/ <br />I 0 <br />2019 <br />AO �N Co N <br />"AfeAtT <br />Area {w ` Emplo5ree ID# N71� vN <br />P SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />EHD 43-06 revised 4/14/16 WELL /PUMP PERMIT <br />