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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEMr 1868 EAST HAzELToN AvEmuE- STOCKToN CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT I:ALL (ZUVI 7103-10U/ FOR INSPECTIONS CAYIKCS T YEAR FROM OATEISSUED <br />ADDRESS 17831 McKinley Ave. CITYrZW Lathrop 195330 <br />SS STREET Vierra Rd. APN 196-150-06 PARCEL SIZE 32.79 LAND USE APPLICATION # N/A <br />IER NAME J.R. Simplot Company PHONE 209-856-6470 <br />IER ADDRESS 16777 South Howland Rd Crry1STATEI7jP Lath -P. CA 85330 <br />TRACTOR Bradley and Sons Drilling PHONE 559-441-1401 <br />TRACTOR ADDRESS 3625 S. Highland Ave. CITY/STATE21P Del Rey / CA 193616 <br />LICENSE X C-57 C-61 - D-09 <br />CITY/STATEITJP, <br />Other NUMBER 414178 <br />EXPIRATION DATE 3/31/2016 <br />GEOGRAPHICAL INFORMATION: Coordinates X -121270997 Y 37.797413 Township _ Range Section <br />INTENDED UsE - Domestic/Private - Irrigation/Agricultural - Industrial X Water Quality Monitoring X Soil Sampling/Characterization <br />- Public Water System <br />If (Afferent from Owner: ate(System Name Contaot Name a Phone Nmber <br />TYPE OF WORK - New Well - Replacement Well - Well Afteration/Modification Other <br />X Monitoring Weil(S) 1 # of wells Soil Boring(s) # ofb°nngs Geotechnical sofboringe <br />Out -Of -Service Weil Out -Of -Service Well Renewal Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 300 ft Excavation 10.625 in diameter Open Bottom X Gravel Pack/Gravel Size #8 sand in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 2 in Thickness/Gauge/ASTM Schad Sch. 40 Steel X Plastic Stainless Steel _ Other <br />Grout Seal Depth 180 ft - Neat Cement (94 1b bag/5-10 gal water) X Sand Cement 10.3 sack mix/1 gal water <br />Bentonite (201A solids) - Other <br />Grout Placement Method X Pumped - Free Fall - Other - Retardant / Accelerator (name) <br />PEDESTA Installed By Driller - Pump Contractor - Other <br />- Concrete Pedestal -Dimensions: Width_j __ft Length_j _ft Thick in X Christy Boz - Stove Pipe <br />PUMP - Submersible Turbine Other HP Pump Set It 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 />MINI M 4 H UR ADV <br />/�/CJE_ NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76697 Q' <br />SIGNED I //EiA'i�-f.�r� TITLE �,'r/ DATE A <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />EPARTMENT US NLY <br />Date <br />Date <br />T <br />�ct��r` <br />Area � Employee ID#� //�{ ` h <br />I SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />y <br />a <br />D <br />0 <br />0 <br />A <br />PE SC <br />Codes Info <br />Receivedec <br />By <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well IDN <br />Service Request # <br />2g7�1 <br />3y <br />!� lg WF0037gi,2 <br />36 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />P N?�4� <br />y�4NhR Nv,N 0041, <br />o 41� <br />OFpq�HTq�M�, <br />MF, yT. <br />