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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(2Q9)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 800 West Mossdale Road ( crrY/ZJP Lathrop, CA 95330 <br /> Interstate 5 239-040-07 <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# o <br /> OWNER NAME Brown Sand, Inc. MZS : PHONE (209)234-1500 <br /> OWNER ADDRESS _ PO BOX 1429 1 gap fj)< ;;�rO CITY/STAT`E/ZJP Lathrop, CA 95330-1429 y <br /> CONTRACTOR V&W Drilling PHONE (209)469-7700 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATE/ZJP Galt, CA 95632 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE VC-57 C-61 D-09 Other NUMBER #720904 ExPIRATON DATE 04/30/20 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring W 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 Other <br /> MonitoringWell(s) #ofwelis ✓SoilBodng(s€B1 - EB15efberinge Geotechnical #ofbedngs <br /> Out-Of-Service Well 1 Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump ;Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUcnON(SOIL BORINGS ONLY) <br /> Drilling Method-/Mud Rotary Air Rotary Auger Cable Tool Push Point V Other 15 Soil Borings t0 60 ft <br /> Proposed Well Depth 60 ft Excavation inchesin diameter Open Bottom Gravef 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 A�n; ft Neat Cement(941b bag/5-10 gal water) Sand Cement sack mixl7 gal water <br /> Bentorote(20%solid.)solids) Other <br /> Grout Placement Method Pumped Free Fall VOther tremee pipe Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller 1 Pump Contractor I Other <br /> Concrete Pedestal Dimensions:width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED -+P — TITLE PG#6795, Condor Earth DATE 10/7/19 <br /> R 4yk, <br /> lirDST 4 ?o, <br /> �iRQNMF ooH9 <br /> oFp NTrY <br /> ��FNT <br /> A MENT U E O LY <br /> Application Accepted By Dat ` Are �SPECIAL <br /> ployee ID# <br /> Grout Inspection By Dale Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boding Inspection By Date L 1 I L U 1 1"I 2� structed Well Depth ft <br /> COMMENTS T I ITI� _ <br /> PE SC Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted, Service Request# <br /> WAP 6 0 40184 <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />