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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186E 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 /> Le <br /> Joe ADDRESS 500 East Louis Avenue CITY21P Lathrop/ 95330 kms <br /> CROSS STREET Cambridge Drive APN 198-120-08@ 869. PARCEL SIZE 1 1 7 aC.LAND USE APPLICATION# N/A o <br /> ASP'RWDi Properties,R&B Louise,LLC and R&B Delta,LLC,GO ECS Corp Roger Ashton 925-969-9245 w <br /> OWNER NAME PHONE <br /> 8 W <br /> OWNERADDREs5 2228 Livingston Street CITY/STATE/ZIP Oakland,CA 94606 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADORESS CITYISTATE/ZIP <br /> SUBCONTRACTOR Middle Earth Geo Testing PHONE 714-633-5025 <br /> SUBCONTRACTOR ADDRESS 954 N.Lemon Street CITY/STATEJZIP Orange,CA 92867 <br /> LICENSE X C-57 C-6i D-C9 Other NUMBER `99431 EXPIRATION DATE 613W202 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomesbuPnvate Imgation,Agncullural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> u Cc11-1"—C-- water Sys—Nana Carted N—a ar,°.w Num°ar <br /> TYPE OF WORK _New Well Replacement Well Well Afteration/Mod lfeabon S Other Cone Penetration Tests(18) <br /> Monitoring Well(s) x of wells Soil Boring(s) 1 J1 Wrngs Geotechnical MotDOO 9' <br /> 7 Out-Of-Service Well Out-Of-Service Well Re^.ewal Cross-COnnecCon Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casio <br /> WELL CONSTRUCTION T <br /> (Drilling Method Mud Rotary Asir Rotary Auger Cable Tool Push Point X Other Dirac L-h f <br /> lProposed Well Depth 30'-50' tip I Excavation 2" in diameter Open Bottom Gravel PackiGravel Size in diameter <br /> Conductor Casing N/A in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter N/A in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 30'-50' ft X Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixt7 gal water <br /> Bentonite(20%solos) Other <br /> Grout Placement Method Pumped Free Fail X Other Tremic Retardant/Accelerator(rame) <br /> PEDE5T4L Installed By Driller Pump Contractor Other <br /> L Concrete Pedestal Dimensions:Width_It Length ft Thick .r. Christy Box Stove Pipe <br /> I PUMP Submersible Turbine Otner HP Pump Set ft Standing Water Level It <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 COM NSA ION LAWS. <br /> 7A.NG -ntjjlji 8 REQUIRED FOA INS <br /> nnFtt7C�r(/JuNb,JOPLEASIE CALL(209)953/-7697 <br /> SIGNED TITLE, f/�/dL`� /"L !" DATE [ -/ <br /> REC�E►d�` <br /> FIVE® <br /> AUG 2 0 2019 <br /> N AQUIN ORONME OUNTy <br /> NTA <br /> LEALTH DEPARTMENT <br /> R T ENTl AD Y <br /> Application Accepted By f� e Area mployee I <br /> Grout Inspection By 1-ky r'•,.` 1--r_L'1_',) Lk4tDate l� Il SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring I spection By Date Constructed Well D pth ft <br /> COMMENTS C �:� r,�. •I 111 SIC <br /> PE SC Received ChecklN Amount Date PermiU Invoice# Well IDI! <br /> Codas Info ash emitted rvi R st _ <br /> O C <br /> EHD SNJ6 rawso0l!1Uts ���/Q�w � ���� /��� .`TELL.'PUMP PERMIT <br />