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Av.t� �„� cili <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS 3150 CJ Stewart Rd (South of Paradise Road) CrrY2P Lathrop, CA, 95330 m <br /> 1cre <br /> 00 <br /> CROSS STREET Fe:'ddi 5e Rodd , C'ohen Rodd APN 21321002 to 007 PARCEL SIZE acres LAND USE APPLICATIONA <br /> ---------------------- <br /> n e 21325001 to 4 ;21021022; 2302100: <br /> OWNERNAME l:'OSSO ,' 2133009 to 010 - 013 to 014 HOME 209-879-7900 <br /> OWNERADDRES3 73 W. Stewart Roale//pl m��ft Crrr/STATE/ZM Lathrop, CA, 95335 <br /> CONTRACTOR Ca is torn_a Push Technol//////ogles, Inc.iGregg Drilling 6 Testing Inc. PNONE 510-357-367'/925-313-5800 <br /> CONTRACTOR ADDRESS 820 Aladdin Avenue i 950 Howe Road CITY/STATE/ZIP San :.eandro, CA, 94577/Martinez, CA 14553 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZP <br /> LICENSE X C-57 C-61 -. D-09 Other NUMBER 884827 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates 37.800111` y-121.351911" Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial -- Water Quality Monitoring X Soil Sam pling!Charactenzauon <br /> Public Water System <br /> If diff—M from ownera er ys em ame Gontad Name or Fham um <br /> TYPE OF WORK New Well - Replacement Well f^Well Alleration/Modification Other CPTS <br /> a c! a nl bonngs <br /> Monitoring Well(s)__III dwelb n ix-.g,Soil Bonng(s) ?: Geotechnical 54 <br /> Ou!-0f-Semce Well L'Oul-Of-Service Well Renewal _Cross-Connection Repair <br /> New Pum - Pump Replacement ri Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool X Push Point Other <br /> Proposed Well Deptn30 to 100ft Excavat;cn tin in diameter _ Open Bottom - Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter i Conductor Casing Depth R <br /> Well Casing Diameter_in Thickness/Gauge.rASTM Sched Steel Plastic Stainless Steel - Other <br /> Grout Seal Depth 30 to 1 0Ot h Neat Cement(94 lb bag/5-10 gat water) Sand Cement sack mrx/7 gal water <br /> Bentonite(20%solids) - Other <br /> Grout Placement Method X Pumped - Free Fall ..Other Retardant i Accelerator(name) <br /> PEDESTAL Installed By _ Drier .. Pump Contractor Other <br /> Concrete Pedestal Dimensions Width it Length h Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine __Other HP Pump Set h 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 /> MINIMUM 24 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TmEStaf_ Engineer DATE 3-.14-17 <br /> 4111 <br /> RECEIVED <br /> MIAN it 2017 <br /> N JOAQU;N COUNTY <br /> ENVIRONMENTAL <br /> Ali ALTH DEPARTMEN-1 <br /> EPA TMENT SE ONLY <br /> Application Accepted Bw- - Dale ( ( __ Area E ployee IDe <br /> Grout Inspection By Date Well Permit <br /> Pump Inspection By Date _ WAIVER Received <br /> r <br /> Soil Boring Ins ection By" _� Date �ZC� Constructed�Well JDepth <br /> '� <br /> CO MENTS �-r/AlGu� L-7't��.�i'L' �_ L-�'f7�=/Z <br /> PE SC Received Ch4lGj& Amount Date Permit/ Invoice M Well IDM <br /> Codes Info By Cash Remitted Service Request M - <br /> 69� / Iso <br /> µ 0! 0 33 <br /> E10:3 rt <br /> \YELL'PVArP PERM' <br />