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114741 WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D1`0cTMENT ' 304 E WEBER °"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED H JOB ADDRESS 16444 S. Manthey Road I 4 -1 e0--/ CITY/ZIP Lathrop 95330 a 0 CROSS STREET Louise APN PARCEL SIZE LAND USE APPLICATION# A OWNER NAME Eugene & Hannah Seus t rc- PHONE 239-7511 OWNER ADDRESS 14384 Blackhawk Way CITY/STATE/ZIP Manteca, CA 95336 CONTRACTOR XKXKXXSXKKXKXXXRffffX Universal Pump PHONE 466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 IN C-61 ❑D-09 ❑Other NUMBER XZX= EXPIRATION DATE 265761 GEOGRAPHICALINFORMATION: Coordinates X Y Township Range Section INTENDED USE mestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chsracterintion ❑Public Water System Ifdiffmomfmm Owner Water ystem No. Comaet Name or Phone Numeor TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) k ofwells ❑Soil Boring(s) #of bonnas ❑Geotechnical aofborinp ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump 12 Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth It Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter c� ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other r� Grout Seal Depth R ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length It Thick in ❑Christy Box ❑Stove Pipe PUMP )Mubmersible ❑Turbine ❑Other HP 1 Pump Set 40 ft Standing Water Level 15 ft T WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uneased ❑Other r711 Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94/h bag/5-/0 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other (�'1 ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE CEO DATE 07/26/04 11 in 1 V7 ZJJJL— LTI DE PAF TMFN] DEPARTMENT USE N Y 3 Application Accepted By L�� Date I Z Area Employ=104 1`tsb q Grout Inspection By Date ❑ SPECIAL Well Permit ` y Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Chee Amount Date Permit/ Invoice# Well ID# Codes Info By ashRemitted Service Request# 3.S! e-so so ev o e Go 3CA 5 EHD4342- MASTER WATER WELL PERMIT L32/2aW