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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 /> 2077 W Yosemite Avenue <br /> JOB ADDRESS CITY/ZIP Manteca 95337 m <br /> CROSS STREET S Airport Way APN 200-140-130-000 PARCEL SIZE 0.757 acLAND USE APPLICATION# o <br /> OWNER NAME Lynn Muy&Mov Hok Tang PHONE N <br /> OWNER ADDRESS 8537 Amares Circle CITY/STATE/ZIP Elk Grove,CA 95757 <br /> CONTRACTOR Middle Earth Geotesting, Inc. PHONE (714)633-5025 <br /> CONTRACTOR ADDRESS 23875 Cabot Boulevard,Unit 323 CITY/STATE/ZIP Hayward,CA 94545 <br /> SUBCONTRACTOR/ NsuLTANT Cornerstone Earth Group PHONE (408)245-4600 <br /> SUBCONTRACTOR! ONSULTAN .ADDRESS 1259 Oakmead Parkway CITY/STATE/ZIP 94085 <br /> LICENSE X C-57 C-61 D-09 _ Other NUMBER 899451 EXPIRATION DATE 06/30/2021 <br /> BILLING PARTY: _ OWNER CONTRACTOR X SUBCONTRACTOR/ NSULTAN�- <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 Other <br /> _. Monitoring Well(s) #of wells x Soil Boring(s) #of borings x Geotechnical 3 #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 _ Auger _ Cable Tool _ Push Point x Other Cone Penetration Testing <br /> Proposed Well Depth 100 ft Excavation 2.5 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 100 ft _XNeat Ce nt(94 Ib,bag/�-�p ga!ware i Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) XOther boring eackttlled wit ' grout per county guidelines <br /> Grout Placement Method Pumped x Free Fall XOther tremae Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> _ Concrete Pedestal _Dimensions:Width ft Length ft Thick in Christy Box _ Stove Pipe <br /> PUMP _ Submersible_ Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY T HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUN DIN CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND A IVE W H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN TIO LAWS. <br /> i,1INIPIUM 48 t VA -E NOTICE REQUIRED FORc INS CT�IOy/NS,- PLEASE CALL (209) 3 7697 <br /> SIGNED TITLE �Q"�" v� DATE <br /> See attached Map <br /> D <br /> T <br /> I I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � Date 7 Area 3&< Employee ID# <br /> Grout Inspection By Date E SPECIAL Well Permit <br /> Pump Inspection By Date l WAIVER Received <br /> Soil Boring Inspection By �� Date 2z Z0Z/ Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount a Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted ervice Re e t# <br /> H3-7d SO / 760 2 <br /> EHD 43-06 6/11/2019 /��I ��L L 1 ' WELL/PUMP PERMIT <br />