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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 /> JOB ADDRESS Near 9820 E Woodward Avenue yV#6 CITY/LP Manteca/95337 m <br /> D <br /> CROSS STREET E Atherton Dr APN 224-050-0150 PARCEL SIZE 66.60 acresLAND USE APPLICATION# o <br /> A <br /> m <br /> OWNER NAME Antoinette Betschart PHONE H <br /> OWNER ADDRESS 558 Woodmont Avenue CITY/STATE/ZIP Berkeley/CA/94708 <br /> CONTRACTOR Taber Drilling PHONE (916)375-8234 <br /> CONTRACTOR ADDRESS 536 Galveston St CITY/STATE/LP West Sacramento/CA/95691 <br /> SUBCONTRACTOR/CONSULTANT Blackburn Consulting PHONE (916)375-8706 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 2491 Boatman Ave CRY/STATEMP West Sacramento/CA 195691 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 969927 ExPIRATION DATE 2/29/2020 <br /> BILLING PARTY: OWNER 1�CONTRACTOR ! SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)L Dibromcchloropropane(4392)" Arsenic(4393) <br /> INTENDED USE D Domestic/Private .Irrigation/Agricultural : Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well C Replacement Well D Well Alteration/Modification Other <br /> D Monitoring Well(s)___ 1r of wells D Soil Borings) *of borings X Geotechnical 2__e of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal Cross-Connection Repair <br /> f"'New Pum [ Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -1 Mud Rotary D Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 12 It Excavation 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 D Plastic ['Stainless Steel : Other <br /> Grout Seal Depth Entire ft X Neat Cement(94/b bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) _Other <br /> Grout Placement Method Pumped X Free Fall Other �i Retardant/Accelerator(name) <br /> PEDESTAL Installed By .Driller I:Pump Contractor Other <br /> D Concrete Pedestal 'Dimensions:Width ft Length ft Thick in Christy Box _.Stove Pipe <br /> PUMP C 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 /> WORKERS COMPENSATION LAWS. <br /> R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Vice President DATE 12.31.2019 <br /> J <br /> E <br /> - - ----- <br /> i <br /> 3 <br /> o at IN I ou Tti <br /> NV Tt NI <br /> A MENT YEO NLYApplication Accepted By to AreaI/��i ee ID# � - 1 <br /> M ' <br /> Grout Inspection By Date C? PECIAL WCII PefitTit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received C Amount Permit/ <br /> Codes Info B a h m'tted at IV Service Re uest# Invoice# Well ID# <br /> W� <br /> EHD 43-06 6/112019 n ��/ -� WELL/PUMP PERMIT <br />