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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 /> m <br /> JOB ADDRESS 300 Brookhurst Blvd / 17774 S Manthey Rd CITY2IP Lathrop, CA m <br /> D <br /> 191-190-32/ 13.26/ o <br /> CROSSSTREET McKee Rd / Brookhurst Blvd APN 191-190-33 PARCEL SIZE 6.89 ac LAND USE APPLICATION# z <br /> m <br /> H <br /> OWNER NAME City of Lathrop PHONE 209-941-7360 y <br /> OWNER ADDRESS 390 Towne Centre Dr CITY/STATE/ZAP Lathrop, CA, 95330 <br /> CONTRACTOR Geo-Ex Subsurface Exploration PHONE 916-799-8198 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP Dixon, CA 95620 <br /> SUBCONTRACTOR ENGEO Incorporated PHONE 209-684-7604 <br /> SUBCONTRACTOR ADDRESS 17278 Golden Valley Parkway CITY/STATE/ZIP Lathrop, CA, 95330 <br /> LICENSE X C-57 0 C-61 3 D-09 = Other NUMBER 954267 EXPIRATION DATE 10-30-20 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE - DomeSliC/Pdvate 71 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring x;Soil Sampling/Characterization <br /> - Public Water System <br /> If different from Owner: Water System Nam Loontact Name or one um er <br /> TYPE OF WORK - New Well - Replacement Well 0 Well Alteration/Modification 2 Other 6 CPTs <br /> Monitoring Well(s) #of wells u Soil Boring(s) #of bo ngs a Geotechnical #of bo ngs <br /> - Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 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 - Auger n Cable Tool N Push Point r Other <br /> Proposed Well Depth 50-65 ft Excavation z 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 0 Plastic - Stainless Steel D Other <br /> Grout Seal Depth 50-65 ft R9 Neat Cement(94 lb bag/5-10 gal water) a Sand Cement sack mixl7 gal water <br /> - Bentonite(20%solids) D Other <br /> Grout Placement Method Xl Pumped 0 Free Fall 0 Other 7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Driller a Pump Contractor Other <br /> -Concrete Pedestal-Dimensions:Width ft Length It Thick in - Christy Box -Stove Pipe <br /> PUMP - SubmersibleC 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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_'�2- TITLE Staff Engineer DATE 06-10-19 <br /> Al <br /> LAI �N <br /> ✓OAQ�/ <br /> //SON N CO(, <br /> NOF�Nr�Iy <br /> rue <br /> PA TMENT ,U[/��,E 0 LY <br /> Application Accepted By Date Ak' t Area mployee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By /01t ,� Date - WAIVER Received <br /> Soil Boring Inspection By r'r�"' _ y Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well 1D# <br /> Codes Info B Cash Remitted Service Request# <br /> (tea b 1 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130/12 y! <br />