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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> La <br /> Joe ADDRESS Near 9820 E Woodward Avenue CITY/LP Manteca/95337 L <br /> D <br /> CROSS STREET E Atherton Dr APN 224.050-0150 PARCEL SIZE 66.64 acre)AND USE APPLICATION# o <br /> m <br /> m <br /> N <br /> LAMER NAME Antoinette BetSChan PHONE y <br /> OWNER ADDRESS 558 Woodmont Avenue CITY/STATE/LP Berkeley/CA/94708 <br /> CONTRACTOR Taber Drilling PHONE (916)375-8234 <br /> CONTRACTOR ADDRESS 536 Galveston St CITY/STATEZP West Sacramento/CA/95691 <br /> SUBCONTRACTOR/CONSULTANT Blackburn Consulting PHONE (916)375-8706 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 2491 Boatman Ave C17Y/STATEZP West Sacramento/CA 195691 <br /> LICENSE x C-57 ❑C-61 ❑0-09 ❑Other NUMBER 969927 EXPIRATION DATE 2/29/2020 <br /> BILLING PARTY: ❑OWNER 0 CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br /> DoMesnc WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 DOmestidPfivafe 0 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring x Soil Sampling/Characterization <br /> 0 Public Water System <br /> If d flerent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well 0 Replacement Well 0 Well Alteration/Modification ❑Other <br /> 0 Monitoring Well(s)`._,_#of wPIIS ❑Soil Borings) #of borings X Geotechnical 2 of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary 0 Air Rotary X Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 12 It Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth Entire ft X Neat Cement(94 Ib bag/5-10 gal watet) ❑Sand Cement sack m&/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped X Free Fall ❑Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor 0 Other <br /> ❑Concrete Pedestal 0Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 0 Submersible 0 Turbine ❑Other HP Pump Set ft 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 /> R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7597 <br /> SIGNED TITLE Vice President DATE 12.31.2019 <br /> T T- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well 1139 <br /> EMD 43.06 6/112018 WELL rPUMP PERMIT <br />