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' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 /> to <br /> JOB ADDRESS 342 Roth Road clrY/zIP Lathrop/95330 m <br /> �J <br /> D <br /> CROSS STREET Harlan Road APN 196-030-020 PARCEL SIZE I'9.N I LAND USE APPLICATION# o <br /> m <br /> OWNER NAME Boral Roofing Company c/o Joaquin Nungaray PHONE 209-275-8703 y <br /> OWNER ADDRESS 342 Roth Road CITYISTATE/ZIP Lathrop/CA/95330 <br /> CONTRACTOR Taber Drilling PHONE 916-371-8234 <br /> CONTRACTOR ADDRESS 536 Galveston Street CITY/STATE2IP West Sacramento/CA/95691 <br /> SUBCONTRACTOR/CONSULTANT Geocon Consultants,Inc. PHONE 916-852-9118 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3160 Gold Valley Drive 4800 CITY/STATE/ZIP Rancho Cordova/CA/95742 <br /> LICENSE iX C-57 r-C-61 F D-09 n Other NUMBER 969927 EXPIRATION DATE <br /> BILLING PARTY: U OWNER u CONTRACTOR U<SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE n Domestic/Private ❑Irrigation/Agricultural ❑Industrial D Water Quality Monitoring a 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 7 Replacement Well c Well Alteration/Modification L Other <br /> MonitoringWell(s) #of wells LSoil Boring(s)- #of borings FxGeotechnical I ofbodngs <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal . Cross-Connection Repair <br /> New Pump L Pump Replacement 7 Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary L Air Rotary it Auger 0 Cable Tool _ Push Point L Other <br /> Proposed Well Depth 15 It Excavation in diameter 7 Open Bottom Gravel Pack/Gravel Size in diameter <br /> 1 1 Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 7 Steel -1 Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth 15 It Ix Neat Cement(94 Ib bag/5-10 gal water) -1 Sand Cement sack mW7 gal water <br /> -1 Bentonite(20%solids) C Other <br /> Grout Placement Method Pumped L Free Fall x Other Tremie L Retardant I Accelerator(name) <br /> PEDESTAL Installed By 7 Driller ❑Pump Contractor 7 Other <br /> Concrete Pedestal uDimensions:Width ft Length ft Thick in L Christy Box L Stove Pipe <br /> PUMP Submersible -Turbine i 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 /> MINIMUry1HOUfj2 Afj11(AN OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED VV �/'"'�I //�� TITLE Sr.Staff Engineer DATE 03/13/2020 <br /> RF yMF <br /> MAR �9 ?0 <br /> V R�01'V <br /> H� NM���N TY <br /> DEPARTMENT USE ONLY (} <br /> Application Accepted By I Date 3 L 0 Area Sw 9/ Employee ID#DGO Il- <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Dale �t WAIVER Received <br /> Soil Boring Inspection By Date 3/710/u'GO Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ AmountDate PermiU Invoice# Well ID# <br /> Codes Info Ca Remitted Service Re est# <br /> �a SO <br /> s6 s <br /> EHD 43-06 6/112019 i ,Y (/( 1 I V/ WELL/PUMP PERMIT <br />