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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 /> JOB ADDRESS 1700 Union Road CITY/ZIP Manteca,CA 95336 y <br /> in <br /> D <br /> CROSS STREET Northgate Drive APN 216-120-01 PARCEL SvE 5 8.3 8 LAND USE APPLICATION# p <br /> A <br /> OWNER NAME Manteca Unified School District-Contact:Justin Geer Constr./Energy Tech. PHONE 209.858.0716 <br /> OWNER ADDRESS 2271 W.Louise Avenue CITY/STATE21P Manteca,CA 95337 <br /> v <br /> O <br /> CONTRACTOR V&W Drillnig-Contact:Karli Stroing PHONE Cell:209.981.7755 <br /> CONTRACTOR ADDRESS 1 133 Blackhurst Drive0 <br /> CITU/STATE/ZIP Galt,CA 95632 0 <br /> SUBCONTRACTOR PHONE O <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE X C-57 C-61 D-09 I I Other NUMBER 720904 EXPIRATION DATE 04/30/2020 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)U Arsenic(4393) n <br /> INTENDED USE 1,Domestic/Private Irrigation/Agricultural Industrial D Water Quality Monitoring Soil Sampling/Characterization Y <br /> 3 Public Water System <br /> U <br /> If different from Owner: Water System Name Contact Name or Phone Number w <br /> TYPE OF WORK D New Well I_Replacement Well ❑Well Alteration/Modification 11 Other <br /> D Monitoring Well(s) #of wells ❑Soil Boring(s) If of borings X Geotechnical I #of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal Cross-Connection Repair <br /> D New Pump Pump Replacement D Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger LCable Tool Push Point _ Other <br /> Proposed Well Depth 50 ft Excavation 4 1/2 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 Schad i Steel 1 Plastic Stainless Steel Other <br /> Grout Seal Depth full depth itNeat Cement(941b bag/5-10 gal water) n Sand Cement sack mixll gal water <br /> Bentonite(20%solids) -other <br /> Grout Placement Method =Pumped D Free Fall X Other Tremie _Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller i, Pump Contractor Other <br /> Concrete Pedestal❑Dimensions:Width ft Length it Thick in n Christy Box Stove Pipe <br /> PUMP Submersible-Turbine 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 A ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS O ENSATION LAWS. <br /> UM4 O R A ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED GE#2295 TITLE Vice President,Engineering Services DATE 05/16/19 <br /> Je <br /> A�I <br /> ?01,' <br /> 04 200 <br /> F'ti'T <br /> PA T M E N T U E O Y <br /> Application Accepted By D to Area mp10yee ID# <br /> Grout Inspection By Date IfJ SPECIAL Well Permit <br /> Pump Inspection By Date }— ❑ WAIVER Received <br /> Soil Boring Inspection By ate 1 1 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedCheck#I Amount Date Permit/ Invoice# Well IDN <br /> odes Info Cas Remitted rvi e, ues # <br /> EHD 43-08 revised 4/14/18 `J WELL/PUMP PERMIT <br />