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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 />IVVIV'r:t_FUNUAtiLL rhHMII www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />5. <br />JQB ADDRESS 1825 Union Road A- i0� 5. (l(7i)m /1RQei ll C CITY/ZIP Manteca, 95337 <br />CROSS STREET Woodward Ave APN p -,/ (! V J PARCEL SIZE l l �s C i LAND USE APPLICATION # <br />OWNER NAME James Lewis PHONE 209-499-2457 <br />OWNER ADDRESS 18251Jnion Road CITY/STATE/ZIP Manteca, CA 95337 <br />CONTRACTOR Middle Earth Geo Testing, Inc PHONE 714-633-5025 <br />CONTRACTOR ADDRESS 954 North Lemon Street CITY/STATE/ZIP Orange, CA 92867 <br />SUBCONTRACTOR/CONSULTANT Geocon Consultants, Inc - Lauren E. Short, PIS PHONE 916.852.9118 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 3160 Gold Valley Drive Suite 800 CITY/STATE/ZIP Rancho Cordova, CA 95742 <br />LICENSE XC -57 ! C-61 D-09 Other NUMBER 899451 EXPIRATION DATE 6/30123 <br />BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private . Irrigation/Agricultural Industrial Water Quality Monitoring X 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 _ Soil Boring(s) _ # of borings XGeotechnical 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 CPT <br />Proposed Well Depth 50 ft Excavation 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 50 ft X Neat Cement (94 11) bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Sentonite (20% solids) Other Hand Dour via <br />Grout Placement Method Pumped Free Fall XOther tremie pipe Retardant / Accelerator (name) <br />PEDESTAL Installed By i Driller Pump Contractor Other <br />r� 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 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 />U E P A R T M E N I U 5 E O N L Y <br />Application Accepted By -��� Date 7 �3 <br />Grout Inspection By Date <br />Pump Inspection By 4 1Date �7 <br />Soil Boring Inspection By Date !/ <br />COMMENTS <br />Area S )Y1Lrt'1 FGc Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received V4CftL <br />Info By 4 Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted e4vice Re ues # <br />L)3 <br />so �Z 3 L <br />47 (vO <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />r <br />r <br />r <br />u <br />