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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 CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 0 <br /> JOB ADDRESS 500 East Louis Avenue cITY/ziP Lathrop / 95330m <br /> D <br /> CROSS STREET Cambridge Drive APN 198-120-080-000 PARCEL SIZE 117 aC LAND USE APPLICATION# N/A o <br /> m <br /> m <br /> OWNER NAME ASP/RWM Properties,R&B Louise,LLC and R&B Delta,LLC,C/O ECS Corp PHONE Roger Ashton 925-969-9245 <br /> OWNER ADDRESS 2228 Livingston Street CITY/STATE/ZIP Oakland, CA 94606 <br /> CONTRACTOR PHONE " <br /> 9t.484 ei!iw <br /> _rca^r c., 1 Rh.a Pies..,.. f n CA Qt5ti6 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR Middle.Earth Geo Testing PHONE 714-633-5025 <br /> SUBCONTRACTOR ADDRESS 954 N. Leinon Street CIT STATE/ZIP Orange, CA 92867 <br /> LICENSE K C-57 1 C-61 D-09 Other NUMB �899-151EXPIRATION DATE 6/30/2019 <br /> DOMESTIC WELL SAMPLING: ._ General Mineral/Coliform Bacteria (4391)L Dibromochloropropane(4392) _ Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial _ Water Quality Monitoring 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 X Other Cone Penetration Tests(six) <br /> Monitoring Well(s) #of wells _. Soil Boring(s) u of borings _.. Geotechnical #of borings <br /> Out-Of-Service Well _ Out-Of-Service Well Renewal _. Cross-Connection Repair <br /> _New Pum_p Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary f Air Rotary Auger Cable Tool Push Point X Other Direct push <br /> Proposed Well Depth 4,ff45vft 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth-0 � �z ft X Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> _ Bentonite(20%solids) Other <br /> Grout Placement Method .. Pumped _ Free Fall X Other TYem1e - Retardant/Accelerator(name) <br /> PEDESTAL Installed By _! Driller __ Pump Contractor Other <br /> Concrete Pedestal Dimensions;Width ft Length ft Thick in _ Christy Box _ Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft 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 COMPEN TION LAWS. <br /> MINIMUM 4 i i0U A V NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED A gjq(Xck_TITLE )�O`cs_e DATE <br /> Q /N <br /> T <br /> M N <br /> PA TMENT U E qNLY <br /> c <br /> Application Accepted By Date l Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL ell Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info A171 Cash Remitted Service Request# <br /> 5a- _4& 2 Zl lq q <br />