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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL (209) 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE <br />`31 Towne Centre <br />Drive INORTHI <br />Lathrop / 9451:. <br />JOB ADDRESS <br />Date <br />SPECIAL 4911 Permit <br />CITY/ZIP <br />Pump Inspect,By <br />. Date <br />Pecan Hollow <br />19155074/19155C75 <br />2.17/1.23 <br />ate <br />CROSS STREET <br />tt <br />APN <br />PARCEL SIZE <br />LAND USE APPLICATION # <br />Carlos Yanez <br />JD �/�(, 0' <br />707-451-E11/ <br />OWNER NAME <br />_ <br />PHONE <br />a r <br />OWNER ADDRESS <br />CITVISTATE/ZIP <br />Geo -Ex Snbsar face <br />xplora[icn <br />916-799-8196 <br />CONTRACTOR <br />PHONE <br />CONTRACTOR ADDRESS 1510 Madera Dr. CITY/STATEgJP Dixon, CA 95620 <br />ENGEO, Inc 209-835-0610 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS 17279 Goiden Valley II CITYISTATE/ZIP CA <br />LICENSE C-57 C-61 D-09 Other NUMBER 9542C7 EXPIRATION DATE 11!30/2020 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE Domestic/Private Irrigation/Agncultural Industrial Water Quality Monitoring x Soil Sampling/Characterization <br />Public Water System <br />If 611—ol from Owner water Iystem Narne Cf,nfacl Narre or oe um <br />OPTS <br />rvcn vvc.r r cH�ar.c,i,c,n ..cn ................�........ .............. <br />Monitoring Wells) # of wells Soil Boring(s) a °r 3eotechnical _ ' Q—e of eonrgs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Aur Rotary Auger Cable Tool X Push Point Other <br />Proposed Well Depth 22 - ft 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 Schetl Steel Plastic Stainless Steel Other <br />Grout Seal Depth -D-50 It x Neat Cement (94 Ib bagr5-10 oaf water) Sand Cement sack mlx17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall x Other - - Retardant / Accelerator (name) <br />PEDESTAL Installed By . Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />1 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 />MlNlm 24 CE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED' TITLE ProT c_[ Engineer DATE 9-5-i9 <br />YMENT <br />x062018 <br />;QulN cou <br />t0lVMENT NTy <br />Dep ART NT <br />PE SC Received <br />Codes Info B <br />pi,'�A T M E N T U 4 E ON LY <br />Date S ice Re uest # Invoice # Well ID# <br />Application Accepted By ' <br />v Date l <br />Area Employee ID# <br />Grout Inspection By <br />Date <br />SPECIAL 4911 Permit <br />Pump Inspect,By <br />. Date <br />- WAIVER Received <br />Soil Boring Inspecbon By <br />ate <br />Constructed Well Depth <br />tt <br />COMMENTS <br />PE SC Received <br />Codes Info B <br />Check#/ AmountPermiU <br />ash Remitted <br />Date S ice Re uest # Invoice # Well ID# <br />(.9 2S6 S 7� / 6ti E:i /nUMa PERMIT <br />EH 43 06 N <br />u30112 <br />'T.�563<30 <br />