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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT UALL (LU`J) `J0J-/bU1 FOR INSPECTIONS LAtoIKtb I TEAR FROM DATE ISSUED <br />JOB ADDRESS 955 S Airport Way Cln./7jp Manteca, CA 95337 <br />CROSS STREET Wawona Street ApN 241-300-430-000 PARCEL SIZE 3 S LAND USE APPLICATION # <br />OWNER NAME Elizabeth Clauser Trust, Mike Clauser, Trustee PHONE 925-918-3505 <br />OWNER ADDRESS PO Box 1884 CITY/STATE/ZIP Manteca, CA 95336-1155 <br />CONTRACTOR Korbmacher Engineering <br />CONTRACTOR ADDRESS 480 Preston Court, Suite B <br />SUBCONTRACTOR California Geotech <br />SUBCONTRACTOR ADDRESS 6886 Village Parkway <br />LICENSE x C-57 L C-61 ❑ D-09 ❑ Other. <br />PHONE 925-454-9033 <br />CITY/STATE/ZIP Livermore, CA 94551 <br />PHONE 831-634-1964 <br />CITY/STATE/ZIP Dublin, California 94568 <br />NUMBER 812382 EXPIRATION DATE 9/30/22 <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring N 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 />SC Received <br />Info B <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings N Geotechnical 1 <br /># of boringsp^ <br />^1I <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />R <br />�CE <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />6 vz U <br />WELL CONSTRUCTION <br />G <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary N Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />-N <br />Proposed Well Depth 20 ft Excavation 4-6 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br />Size 4Ivgdiamete <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />/yEENV/Ro Ul/� <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel <br />❑ Other ATN NMF <br />Grout Seal Depth Full Depth ft ® Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement <br />sack mix17 6a- <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped N Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />3EDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DE PARTM E NT U S E ONLY <br />Application Accepted By L L Date 3l "?'R <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil BoringInspection By Date y�L <br />COMMENTS ' y&Wtl e- +6 le t/Se J �r C f o UYI dv✓atfee i' pomov <br />Area 3 i�Cti''t}QLOk %Employee ID# A5 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />L <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ <br />Cash <br />Amount Permit/ <br />Remitted Date ervice Re uest # Invoice # Well ID# <br />3-7R <br />I S a <br />Ste- <br />6 vz U <br />EHDO43-06 04/07/2022 Page I of 2 Well) Pump Permit <br />