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RECEIVFn <br /> AUG 12 2019 <br /> WELL/PUMP PERMIT ���`��' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 952054232`(2 %AWNAIEN-1AL HEALTH <br /> NON-REF UNDAB E ERMIT - www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSLIJJ) 1>,�ItTNIENT <br /> Joe ADDRESI J owland Road crryov, Lathrop 95023 m <br /> D <br /> CROSS STREET East Louise APN 19818008 PARCEL SIZEZ I LAND USE APPLICATION# <br /> OWNER NAME Simplot PHONE 209-858-2511 a <br /> OWNER ADDRESS 16777 Howland Road CITY/STATE/ZIP Lathrop,CA 95023 <br /> CONTRACTOR Pitcher Services,LLC PHONE 650-328-8910 <br /> CONTRACTOR ADDRESS 216 Demeter St CITY/STATErOP East Palo Alto,CA 94303 <br /> SUBCONTRACTOR/CONSULTANT Geosyntec Consultants,Inc. PHONE 916-637-8334 <br /> SUBCONTRACTOWCONSULTANT ADDRESS 3043 Gold Canal Dr.,Suite 100 Cr Y/gTATEMp Rancho Cordova,CA 95670 <br /> LICENSE X C-57 :1 C-61 J D-09 0 Other NUMBER 1044895 ExPiRAT1ON DATE <br /> &LUNG PARTY: -OWNER I CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)1 Dibromochloropropane(4392) 1 Arsenic(4393) <br /> i INTENDED USE D Domestic/Private C Irrigation/AgriCultural C Industrial ❑Water Quality Monitoring X Soil Sampling/Characterization <br /> D Public Water System <br /> N Afferent bpm Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well C Replacement Well D Well AReration/Modification D Other <br /> D Monitoring Well(s) #of wells ❑Soil Boring(s) a of borings 3 Geotechnical 4 e of borings <br /> D Out-Of-Service Well C Out-Of-Service Wed Renewal l]Cross-Connection Repair <br /> 0 New Pum ..Pump Replacement -- Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 3 Mud Rotary U Air Rotary 1l Auger D Cable Tod r Push Point ❑ Other <br /> (Proposed Well Depth 3070•,IC110' it Excavation in diameter ❑Open Bottom C Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth fI <br /> Well Casing Diameter NA In Thickness/Gauge/ASTM Schad C Steel J Plastic C Stainless Steel O Other <br /> Grout Seal Depth total depth It a Neat Cement(94 Ib bag/5-10 gal water) 7 Sand Cement sack man gal water <br /> C Bentonite(20%solids) O Other <br /> Grout Placement Method -Pumped D Free Fall 2 Other UBMjg C Retardant I Accelerator(name) <br /> FEEMLSTAI Installed By I I Odder :;Pump Contractor D Other <br /> -1 Concrete Pedestal DDlmensions:Width It Length R Thick in C Christy Box C Stove Pipe <br /> PUMP C Submersible]Turbine n Other HP Pump Set R Standing Water Level R <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 /> MINIMU 8 HO TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2091953-7697 <br /> SIGNE TITLE 1 10 DATE / r� 7/ <br /> �Al <br /> 4�/Vp® <br /> NG <br /> -C <br /> QUIN C <br /> OUPM <br /> NRMEN <br /> PA MENT Ulyt. OtYLY <br /> Application Accepted 8 Date Area mployee ID# <br /> Grout Inspection By `l�'>rtLIt�L7 �F>DiA-1Q.AAA Dale SPECIAL Wel Permit <br /> I Pump Inspection By Date I WAIVER Received <br /> I <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Amount Permit/ Invoice# Well IDS <br /> Codes Into By Cash Date <br /> emitted Service Re oast/ <br /> it <br /> EHD 43-08 &1112019 WELL/PUMP PERMIT <br />