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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 16300 McKinley Avenue CITy/ZIP LATHROP/95330 m <br /> D <br /> CROSS STREET East Louise Avenue APN 198-100-11 PARCEL SIZE 5.0 Acres LAND USE APPLICATION# v <br /> a <br /> A <br /> OWNER NAME Dilbagh Singh PHONE m <br /> OWNER ADDRESS 16300 McKinley Avenue CITY/STATE21P LATHROP/CA/95330 <br /> CONTRACTOR West Coast Exploration PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS 1540 Roosevelt Avenue CITY/STATE/ZIP ESCALON/CA/95320 <br /> SUBCONTRACTORICONSULTANT CTE CAL,INC. PHONE (209)543-1799 <br /> SUBCONTRACTORICONSULTANT ADDRESS 4230 Kiernan Avenue,Suite 150 CITYISTATE/ZIP MODESTO/CA/95356 <br /> LICENSE X C-57 ❑C-61 ❑D-09 ❑Other NUMBER 670761 E%PIRATION DATE 01/31/2020 <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigabon/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdifferent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) #of wells D Soil Boring(S) 0 ofbodngs Geotechnical 3 0 of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑ Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 15 ft Excavation 4 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 ft X Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ,Free Fall ❑Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in D 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 COMPENSATION LAWS. <br /> MINIMUM <br /> ,48 HOUR/ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Staff Geologist DATE 1 0/2 512 01 9 <br /> S E JE I JAITIT A C H E D <br /> FC�IVNT <br /> r <br /> FO <br /> ?g ?419 <br /> D-E-P R T M E N T U SEELY <br /> Application Accepted By r"~' Date w Area / Employee ID# <br /> Grout Inspection By Date 11 /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#1 Amount D e Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> 0040224 <br /> 9504306 6/11x2019 WELL/PUMP PERMIT <br />