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I <br />MLL/PUMP PERMIT <br />SAN JOAOuIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www SJgoy.Org/entf <br />t1CYIKtA T TEAR FROM DATE 155UEU <br />JOB ADDRESS 1965 S. Union Road <br />CITYIZIP <br />Manteca 95337 <br />226-180-16 <br />t <br />3 y <br />CROSS STREET Woodward Ave APN <br />PARCEL SIZES <br />LAND USE APPLICATION # <br />OWNER NAME James Lewis S!1111t 1-12114�5 <br />PHONE 209-499-2457 <br />OWNER ADDRESS 1825 South Union Road <br />CITY/STATEiZIP <br />Manteca 95337 <br />CONTRACTOR Slagle Drilling <br />PHONE 916-363-9355 <br />CONTRACTOR ADDRESS 3369 Fitzgerald Road <br />Cm/STATEIZIP <br />Rancho Cordova CA 95742 <br />SUBCONTRACTORICONSULTANT Geocon Consultants, Inc - Lauren E Short, PG <br />PHONE 916.852.9118 <br />SUBCONTRACTORICONSULTANT ADDRESS 3160 Gold Valley Drive, Suite 800 <br />CITYISTATE/Z1P <br />Rancho Cordova, CA 95742 <br />LICENSE rXG57 -i C-61 C D-09 C Other <br />NUMBER 1046151 <br />EXPIRATION DATE 10/31122 <br />BILLING PARTY: 7 OWNER C CONTRACTOR Cit SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General MineraMol'Iforrn Bacteria (4391) i7 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE E. Domestic(Private C Irrigation/Agricultural C Industrial 0 Water Quality Monitoring IX Soil Sampling/Characterization <br />�. Public Water System <br />If different from Owner. Water System Nam Contact Name or Phone Number <br />TYPE OF WORK New Well D Replacement Well 7 Well Alteration/Modification C Other <br />Monitoring Well(s) # of wells -I Soil Boring(s) n of borings rXGeotechnical 5 n of borings <br />C Out -Of -Service Well C Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />N.- P.— , i Pu -n Raniarcmant i, Pum. Renoir i i Raise Well Casino <br />Drilling Method Mud Rotary i Air Rotary xquger i Cable Tool i i Push Point i i Other <br />Proposed Well Depth 15 ft Excavation 6-8 in diameter Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad 7 Steel C Plastic 0 Stainless Steel C Other <br />Grout Seal Depth 15 it 7Weat Cement (94 1b bao-10 gal water) -i Sand Cement sack mix17 gal water <br />;j Bentonite (20% solids) 7 Other hand Dour via <br />Grout Placement Method _I Pumped 0 Free Fall X Other tremte Pipe ❑ Retardant /Accelerator (name) <br />PEDEsr- Installed By L Driller C Pump Contractor 0 Other <br />0 Concrete Pedestal CDimensions: Width ft Length It Thick in 0 Christy Box = Stove Pipe <br />PUMP 0 Submersible-, Turbine 0 Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 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 AC71VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS OMPENSAT10N LAWS. <br />m HOUR A ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />I TITLE President DATE nam919091 <br />,a,, J Employee ID# A6 - <br />El <br />V❑ SPECIAL Well Permit <br />WAIVER Recelved <br />Constructed Well Depth ft <br />DEPARTMENT U E ONLY <br />Application Accepted By� <br />Date <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />Date <br />Date 90�u <br />COMMENTS <br />,a,, J Employee ID# A6 - <br />El <br />V❑ SPECIAL Well Permit <br />WAIVER Recelved <br />Constructed Well Depth ft <br />EHD 43-6 6/112010 WELL /PUMP PERMIT <br />b <br />21 <br />NTY <br />L��f1����E�►�K1�3flR <br />��i1'������ <br />EHD 43-6 6/112010 WELL /PUMP PERMIT <br />b <br />21 <br />NTY <br />