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r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2ELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1953 London Ave. CITYIZIP Manteca, CA 95336D <br /> CROSSSTREET Komenich Dr APN 20229033 PARCELSIZE 9•0 LAND USE APPLICATION# O <br /> N Vr /� t=l/1 m <br /> OWNER NAME �,�`/�� /' '�J� ��'• PHONE <br /> OWNER ADDRESS �lJy� ' 4 C-cam/( - CITYISTATEIZIP. <br /> CONTRACTOR Kleinfelder. PHONE 209.948.1345 <br /> CONTRACTOR ADDRESS 2001 Arch—Airport: Road, Suite 100 CITY/STATEIZIP Stockton, CA 95206 <br /> SUBCONTRACTOR V&W Drilling, Inc. PHONE 209.469.7700 <br /> SUBCONTRACTOR ADDRESS 1133 Blackhurst Dr CITYISTATEfZIP Galt, CA 95632 I, <br /> LICENSE Y-C-57 D C-61 ❑ D-09 D Other NUMBER 720904_ EXPIRATION DATE 04/30/2020 <br /> DOMESTIC WELL SAMPLING:❑General MineraUCoiiform Bacteria(4391)7 Dibromochloropropane(4392)7 Arsenic(4393) <br /> INTENDED USE L DomestlC/Private u Irrigation/Agricultural U Industrial U Water Quality Monitoring x Soil Sampling/Characterization <br /> F- Public Water System <br /> It different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well -i Replacement Well D Well Alteration/Modification D Other <br /> CMonitoring Well(s) #of wells DSall Boring(s) #ofbortngs RGeotechnicai 1 8ofborings <br /> L Out-Of-Service Well U Out-Of-Service Well Renewal u Cross-Connection Repair <br /> F New Pump n Pum Re Iacemenl r Pump Repair -1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r Mud Rotary 1-1 Air Rotary XAuger r Cable Tool n Push Point L Other <br /> Proposed Well Depth 20 It Excavation 6 In diameter D Open Bottom D Gravel Pack/Gravel Size in diameter <br /> O Conductor Casing In diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel I I Piastic I Stainless Steel I I Other <br /> Grout Seal Depth 20 ft XNeat Cement(94 Ib bag15-10 gal water) n Sand Cement sackmixA gal water <br /> Ll Bentonite(20%solids) u Other <br /> Grout Placement Method n Pumped rxFree Fall n Other n Retardant/Accelerator(narne) <br /> PEDESTAL Installed By u Driller u Pump Contractor u Other <br /> C Concrete Pedestal❑Dimensions;Width ft Length ft Thick In 7 Christy Box D Stove Pipe <br /> PUMP C Submersible❑Turbine :1 Other HP Pump Set R 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 /> I IMUM 48 H.GH A VANCE NOTICE REQUIRED F IyyN\`SPECT+IONS-PLEASE CALL(209)953-769 <br /> SIGNED 1 TITLE�' O' 7 l�l-(1�.4A����� DATE <br /> Ypp�p <br /> jk <br /> i® <br /> 018 <br /> Nay <br /> NT <br /> D •PA MENT U E 0 <br /> aL <br /> Application Accepted By Date �G Area /���Ioyee ID#jI� <br /> Grout Inspection By Data ig ❑ §PECIALWOII Permit <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS - -__ <br /> PE SC Received Check#1 Amount Date Permild Invoice# Well ID# <br /> Codas Info Cash R ml ed ervice Wuast# <br /> EHD4306 rerised4f14hS ��/��� I�� WELL HUMP PERMR <br />