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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 PERMIT1 www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 6l�� to <br /> JOB ADDRESS I- p�G _ ffl on CITY21P Manteca/95336 m <br /> Closest cross street bD <br /> CROSS STREET Union Rd.and Shady Pines SL APN 197-0223.OR t7Z PARCEL SIZE 28.15 LAND USE APPLICATION# o <br /> OWNER NAME ert OYCe at I SN/ KooNM4I PHONE 209.234.40 14 (} <br /> OWNER ADDRESS-P-'e- " P 9,3)11HI"t7 CITY/STATE/ZIP P;Ckl-74pj J 3 <br /> CONTRACTOR V&W Drilling-Contact:Karli Stroing PHONE 209.981.7755 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATEIZIP Galt,CA 95632 <br /> SUBCONTRACTOR/CONSULTANT Condor Earth Technologies,Inc.-Contact:Kaleb Ledford PHONE 209.756.4323 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 188 Frank West Circle,Suite I CrTY/STATE/ZIP StOCICton,CA 95206 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 720904 EXPIRATION DATE 04/30/2022 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification *X Other Piezometers <br /> Monitoring Well(s) #of wells Soil Borings) #of borings *X Geotechnical 2 a of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 25 It 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth full depth ft X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall X Other Tremie Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible 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 /> MI OUR I,I I WE0'P-jFREQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Project Coordinator DATE 11/11/20 <br /> l <br /> YE��VT <br /> Vie® <br /> 7 .2020 <br /> CQM COUN7Y <br /> ART 46 <br /> MENT <br /> /DEPARTMENT USE ONLY ? <br /> Application Accepted By � �!r Date I h7 0�00�'b Area `� Employee ID# G <br /> Grout Inspection By Date J4/ 2A) SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inj�pection By Date Constructed Well Depth ft <br /> COMMENTS /{- <br /> PE SC Received Check#/ Amount Date Permltl Invoice# Well ID# <br /> Codes Info By. Cash Remitted SsWce a uest# <br /> 37d ISd *609 imnTo <br /> Wyo <br /> I <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />