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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> JOB ADDRESS 241 E.4th Street CITY/ZIP French Camp,CA 95231 m <br /> CROSS STREET Elm Street APNjq3 IS PARCEL SIZELAND USE APPLICATION# o <br /> OWNER NAME Manteca Unified School District-Contact:Mike Lehr,Constr./Energy Tech. PHONE 209.858.0955 rNir <br /> OWNER ADDRESS 2271 W.Louise Avenue CITY/STATE21PManteca,CA 95337 p <br /> CONTRACTOR V&W Drilling-Contact:Karli Stroing PHONE Cell:209.981.7755 <br /> A <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive Crry/SrnrE21P Galt,CA 95632 <br /> A <br /> ti <br /> SUBCONTRACTOR PHONE ry <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP <br /> 5 <br /> LICENSE Iii'C-57 Li C-61 ❑D-09 U Other NUMBER 720904 EXPIRATION DATE 04/30/2020 T <br /> (7 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)L.1 Dibromochloropropane(4392)C1 Arsenic(4393) <br /> v <br /> INTENDED USE Domestic/Private Irrigation/Agricultural F1 Industrial F]Water Quality Monitoring ❑Soil Sampling/Characterization C) <br /> Public Water System y <br /> If different from Owner: Water System Name Contact Name or Phone Number �O <br /> tA <br /> N <br /> TYPE Or WORK New Well Replacement Well i�Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑Soil Borings) #of borings X Geotechnical 5 If of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Ll Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary ❑Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 10 to 50 ft Excavation 4.5 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel 'I Plastic Stainless Steel L Other <br /> Grout Seal Depth Full Depth ft X Neat Cement(94 111,bag/5-10 gal water) -Sand Cement sack mix/7 gal water Pe <br /> - Bentonite(20%solids) i Other _7 YV <br /> Grout Placement Method 11 Pumped 11 Free Fell X Other Tremie Retardant/Accelerator(name) RFC;'�NT <br /> PEDESTAL Installed By Driller 0 Pump Contractor Other � rO <br /> -Concrete Pedestal❑Dimensions:Width ft Length ft Thick in D Christy Box ❑Stove Pipe A^ <br /> PUMP Submersible_L Turbine D Other HP Pump Set It Standing Water Level M <br /> A <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SA <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENS�/ qQU//N CO <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH A RaNj " UN <br /> WORKERS COMPENSATION LAWS. DF�j FM,ql <br /> MINIMU H U AD ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 �T/14EHT <br /> SIGNED TRLEVice President,Engineering Services DATE 03/22/19 <br /> date <br /> a <br /> PA TRA ENT USE O LY <br /> ♦ '/ <br /> Application Accepted By Date AZ Area liq Employee ID# <br /> Grout Inspection By Date i 1 PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By _ Date , Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> odes Info ash mi d ice Request# <br /> EHD 43-0e revised 4/14/18 WELL(PUMP PERMIT <br />