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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 300 Brookhurst Blvd / 17774 S Manthey Rd CITY/Zip Lathrop, CA D <br /> 191-190-32/ 13.26/ o <br /> CROSS STREET McKee Rd / Brookhurst Blvd APN 191-190-33 PARCEL SIZE 6.89 ac LAND USE APPLICATION# A <br /> m <br /> N <br /> OWNER NAME City of Lathrop PHONE 209-941-7360 H <br /> OWNER ADDRESS 390 Towne Centre Dr CITY/STATE/ZIP Lathrop, CA, 95330 <br /> CONTRACTOR West Coast Exploration PHONE 209-985-7541 <br /> CONTRACTOR ADDRESS PO Box 133 CITY/STATE/ZIP Eecalon, CA 95320 <br /> SUBCONTRACTOR ENGEO Incorporated PHONE 209-684-7604 <br /> SUBCONTRACTOR ADDRESS 17278 Golden Valley Parkway CITY/STATE/ZIP Lathrop, CA, 95330 <br /> LICENSE RJ C-57 ❑C-61 7 D-09 - Other NUMBER 870761 EXPIRATION DATE 1-31-20 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE - Domestic/Private 7 Irrigation/Agricultural n Industrial D Water Quality Monitoring N Soil Sampling/Characterization <br /> - Public Water System <br /> If different from Owner: Water System Name o a ame or Phone Number <br /> TYPE OF WORK -New Well - Replacement Well ❑Well Alteration/Modification D Other <br /> Monitoring Wells) #of wells N Soil Boring(s) 5 #of borings U Geotechnical #of borings <br /> - Out-Of-Service Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pum - Pump Replacement n Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary -Air Rotary x Auger n Cable Tool n Push Point F- Other <br /> Proposed Well Depth 15-25 ft Excavation 4 in diameter :1 Open Bottom -1 Gravel Pack/Gravel Size in diameter <br /> - Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 7 Steel ❑Plastic ❑Stainless Steel D Other <br /> Grout Seal Depth 15-25 ft P9 Neat Cement(94 lb bag/5-10 gat water) U Sand Cement sack mix/7 gal water <br /> - Bentonite(20%solids) D Other <br /> Grout Placement Method rn Pumped ❑Free Fall ❑Other -1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Driller U Pump Contractor Other <br /> - Concrete Pedestal-Dimensions:Width it Length it Thick in - Christy Box �Stove Pipe <br /> PUMP - Submersible" Turbine F1Other 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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED (i�^^^"� TITLE Staff Engineer DATE 06-10-19 <br /> PA <br /> Jt/N <br /> �oAQ�1 4 2®19 <br /> A -00 �jRON N COU <br /> N UFpgR����Y <br /> R ENT USE O LY <br /> Application Accepted By ` ate 6/ Are.'j/ ployee ID# <br /> Grout Inspection By Date /// SPECIAL Well Permit <br /> Pump Inspection By Date - WAIVER Received <br /> Soil Boring Inspection By A Date Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 4WELL/PUMP PERMIT <br /> 4/30/1230112 <br />