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• l <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE LTON AVENUE-STOCKTON CA 95205 - (209) 466-3420 <br />NON-REFUNDABLE PERMIT <br />CALL (20%9) 953-7697 FOR IN5PECTIONS <br />rArIKII T TtAH YKUM UAIC IJJ <br />PECIAL We---ermil <br />Pump Inspection By Date <br />WAIVER Recelved <br />Soil Boring Inspection By Date <br />Constructed Well DepthK <br />JOB ADDRESS <br />2�1 ;osrnc Cert <br />re Crive f. SiiC7E! d,�3 <br />� CITY/Zip <br />Lathroc ! 54513 <br />���� 76 WELL /PUMP PERMIT <br />Pc Hollow• <br />19170014 r � <br />-ARCEL <br />Z. 4E <br />CROSS STREET <br />Can <br />APN / <br />SIZE <br />LAND USE APPUCATON 0 <br />Carlos Yar-ez <br />JD/t�L��a �7 <br />707-451-P111 <br />OWNER NAME <br />PHONE <br />f <br />`/ <br />OWNER ADDRE33 <br />'n, <br />f�_ J T 2- -z- C-1 <br />CITYISTATE/ZIP <br />C 't <br />— <br />CONTRACTOR <br />Wes =_ <br />West Coat Exploration, <br />Inc <br />PHONE 209-985-7543 <br />R ADDRESS P.O. Box 133 <br />ENGEO- Inc <br />CTOR <br />CTOR ADDRESS 172'78 Golden Valley Parkway <br />C-57 C-61 0-09 Other_ <br />NUMBER <br />Cn'YfSTATE/Z1P <br />Escalon, CA 95320 <br />CITYISTATE/ZIP <br />87071,1 <br />209-895-OE10 <br />_ PNONE <br />1%2020 <br />EXPIRATION DATE /3 <br />'iEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br />NTENDED USE . Domesbc/Pnvate IrrigabonlAgncultural Industrial Water Quality Monitonng x Soil Sampling/Characterization <br />Public Water System <br />If tl,eerenl hem Owner Water SyStem Narre CorgAd Name or PhOW NuMber <br />TYPE OF WORK New Well Replacement Well Well Alteration/Mpdifi tion ". Other <br />Monitoring Wells) # of wells x Soil Boring(s) e of b°nng' o°ne <br />Geotechnical a oI b' <br />Cross -Connection Out -Of -Service Well Out -Of -Service Well enewal -. Repair <br />New PumD Pump Replacement Pump Repair Raise Well Casing <br />Drilling Method Mud Rotary Air Rotary x Auger Cable Tool Push Point Other <br />Proposed Well Depth 2" If Excavation 4 in diameter Open Bottom Gravel PacJdGravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schetl Steel Plastic Stainless Steel Other <br />Grout Seal Depth 20 It x Neat Cement (94 In bagi5-10 gat water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method ._ Pumped Free Fall x Other - - Retardant / Accelerator (name) <br />PEDEITA, Installed By Driller Pump Contractor Other <br />Concrete Pedestal DimensionsWidth R Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set___ R 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 />�� E REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED'""_/.-_ _— TITLE Pro?eco F.naincer DATE 9-5-1E <br />_N <br />06 2018 <br />OV COUNry <br />PAR M E N T US O Y <br />Application Accepted By a Date �� <br />Area ✓ �'ployee ID# j�� <br />Grout Inspection By Date <br />PECIAL We---ermil <br />Pump Inspection By Date <br />WAIVER Recelved <br />Soil Boring Inspection By Date <br />Constructed Well DepthK <br />Cr1MMFNTS <br />PE SC Received Chfick#J <br />Amount Permit/ <br />Date Invoice # Well ID# <br />Codes Info B ash <br />emitted Service Request # <br />WP66587(1 <br />EhU /r <br />ul'J,12 12 //Vfl/tl-y�I <br />���� 76 WELL /PUMP PERMIT <br />4 72—S -630i77 <br />