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MLUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 1495 S Union Rd OITy/ZIp Manteca/95337 m <br /> D <br /> CROSS STREET W Atherton Dr ApN 226-16-035 PARCEL SIZE 31 a Acres LAND USE APPLICATION# o <br /> M <br /> m <br /> OWNER NAME Demetri Filios PHONE 209-490-2313 y <br /> OWNER ADDRESS 1463 Moffat Blvd,Ste 5 CITY/STATEIZIP Manteca/CA/95336 <br /> CONTRACTOR West Coast Exploration Inc PHONE 209-985-7541 <br /> CONTRACTOR ADDRESS P.O.Box 133 CITY/STATE0p Escalon/CA/95320 <br /> SUBCONTRACTOR/CONSULTANT CTE CAL Inc PHONE 209-543-1799 <br /> SUBCONTRACTORICONSULTANT ADDRESS 4230 Kiernan Ave Ste 150 CITYISTATEIZIP Modesto/CA/95356 <br /> LICENSE IN C-57 ❑C-61 ❑D-09 ❑Other NUMBER 670761 ExPIRATION DATE 1/31/2022 <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR Ili SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)�]Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring R Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdilferent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑ Replacement Well ❑Well AReration/Modification ❑Other <br /> 0 Monitoring Well(s) #of wells ❑Soil Boring(s) 0 ofbonngs 11 Geotechnical 6 s 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 0 Mud Rotary ❑Air Rotary 0 Auger 0 Cable Tool C Push Point ❑ Other <br /> Proposed Well Depth 30 ft Excavation 4 inches in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> 0 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 30 ft 11 Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped 0 Free Fall a Other tremie it in r Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length It Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersibleii 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 /> MINIM/U�M� 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Staff Geologist DATE 2/26/21 <br /> S E JE I AIT IT A C H I E <br /> cu <br /> f <br /> AfQr N7-y <br /> DEPARTMENT US ONLY 1 p <br /> Application Accepted By �-�" /G� ..- Date Area Employee ID# -� <br /> Grout Inspection ByDate ElSPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Baring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check* Amount Dae Permit/ Invoice# WeIIID# <br /> Codes Info B Cash Remitted a Nce Re uest# <br /> EHD4308 N112019 WELL/PUMP PERMIT <br /> C : 2-I ZyCo 3-4z3 <br />