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r' . , <br />1 WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />1VVIV-KEFUNDABLE PERMIT t,:ALL (ZU9) 953.7597 FOR INSPECTIONS EXPIRIES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5055 French Camp Road p�r� r� c,TY/z,P Manteca, CA 95336 <br />CROSS STREETS Frontage Road APIA 20 4 1-0f� 50-070-000 PARCEL SIZE ) 1 , S LAND USE APPLICATION# <br />OWNER NAME L3gorio Properties PHONE (209) 932-0734 <br />OWNER ADDRESS 777 N. Pershing Avenue CITY/STATE/ZIP Stockton, CP_ 95215 <br />RACTOR BSK Associates <br />RACTOR ADDRESS 550 W Locust Avenue <br />BSK Associates <br />ADDRESS 550 W Locust Avenue <br />PHONE (209) 769-4734 <br />CRY/STATE/ZIP Fresno, CA, 93650 <br />PHONE (209) 769-4734 <br />CITYISTATEIZIP Fresno, CA, 93650 <br />$ C-57 C-61 ! 0-09 ! Other NUMBER 490942 EXPIRATION DATE 12131 /2022 <br />DOMESTIC WELL SAMPLING: O General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE tj DomesticlPrivate .i Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />n Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK o New Well Replacement Well Well Alteration/ModiticalIon ❑ Other <br />J Monitoring VVell(s) # of wells _ Soil Boring(s)R orbonngs N Geotechnical 3X10' sol borings <br />u Out -Of -Service Well _: Out -Of -Service Well Renewal o Cross -Connection Repair <br />J New Pumn I Pumo Renlacement Pumo Repair i 1 Raise Well Casino <br />Drilling Method ❑ Mud Rotary Air Rotary ..j Auger ? Cable Tool -� Push Point X Other hand auger borings <br />Proposed Well Depth 10 d Excavation 4° in diameter -i Open Bottom Ci Gravel Pack/Gravel Size, in diameter <br />D Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad a Steel ❑ Plastic 0 Stainless Steel - Other <br />Grout Seal Depth 16 ft X Neat Cement f94 1b boo -10 gal water) Sand Cement sack mW7 ga <br />Bentonite (20% solids) D Other <br />Grout Placement Method a Pumped X Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By n Driller C• Pump Contractor Other <br />Concrete Pedestal F! Dimensions: Widlh ft Length ftThick <br />in _ Christy Box F Stove Pipe <br />Pump Submersible ❑ Turbine L. Other HP Pump Set ft Standing Water Lev1$I - ' ° fK <br />Plot Plan Requirements: Attach a pilot plan with the exact location of water well with respect to the following items: <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers Dr private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINIMUM 23 HOUR 1D\ \VLF. YOTICF RFQL'IRF.D FOR t VSPFrTIONS � PI,F,VF. t -V 1 (309) 951 7597 <br />DEPARTMENT USE ONLY <br />Application Accepted By—�—�'ate 3 ,73 1' Area ��� Employee IDs <br />Clout Inspection By / 6 �---mate ❑ SPECIAL Well, Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Baring Inspection ft <br />{nspection By Date Constructed W9LII Depth <br />� <br />COMMENTS _-LtP1'Y1e ;: C-f�j,f' �.�('( If <br />PE SC Received Check#! Amount Date PermtV Invoice # Well ID# <br />Codes Info By_ cash Remitted §ervIce R uest # <br />7d 0 MA MCI <br />EH0043 06 10 25 2021 pq' 1 or? 1k,11 Pump Pamir <br />M <br />n <br />v <br />v <br />4 <br />AfA- <br />CD <br />2022 <br />r"/V7' Y <br />�MCNT <br />