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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT — www.sj2ov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS Approximately 1,000'west of 184�('^Iry CrrY21P Lathrop/95337 a <br /> m <br /> Bet\veen Yoeemte Avenue end RR Trach D <br /> CROSS STREET ppN_2.41-400-26 PARCEL SIZE 10 a ra' LAND USE APPLICATION# o <br /> OWNER NAME City of Lathrop PHONE 209-941-7200 <br /> OWNER ADDRESS 390 Towne Center Cm/STATE/ZIP Lathrop,CA 95330 <br /> !CONTRACTOR Bradley and Sons Drilling and Pump Systems PHONE 559-441-1401 <br /> CONTRACTOR ADDRESS 3625 S.Highland Avenue Cm/STATEIZIP Del Rey,CA 93616 <br /> SUBCONTRACTOR/CONSULTANT Luhdorfi and Scalmanini Consulting Engineers PHONE 530-661-0109 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 500 First Street CmrISTATE/ZfP Woodland,CA 95695 <br /> LICENSE x C-57 C-61 D-09 Other NUMBER 414176 E%PIRATION DATE 11/30/2021 <br /> BILLING PARTY: D OWNER CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)f,Dibromochloropropane(4392)i Arsenic(4393) <br /> INTENDED USE DOm@Stic/Private IrrigatiorVAgricultural 7 Industrial Tt Water Quality Monitoring __Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Nenw Contact Name or Phone Number <br /> TYPE OF WORK New Well L Replacement Well I Well Alteration/Modification -!Other <br /> k Monitoring Well(s) 3 #of wells 1 Soil Boring(s) a of bonOge Geotechnical If of bonngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump IT Pump Re lacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method z.Mud Rotary _:Air Rotary Auger Cable Tool i Push Point -1 Other <br /> Proposed Well Depth 300 ft Excavation 12.25 in diameter I!Open Bottom x Gravel Pack/Gravel Size SRI t8 in diameter <br /> Conductor Casing In diameter / Conductor Casing Depth ---ft <br /> Well Casing Diameter 2 in Thickness/Gauge/ASTM Schad 40/F480-88A Steel x plastic !Stainless Steel 1 Other <br /> Grout Seal Depth 160 R Neat Cement(94 Ib bag/5-10 gal water) X Sand Cement l Q.S sack mix/7 gal water <br /> Bentonite(20%solids) i Other I <br /> j Grout Placement Method xl Pumped Free Fall Other 7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By x Driller it Pump Contractor Other <br /> I Concrete Pedestal LDimensions:Width fl Length ft Thick in x Christy Box I Stove Pip-- <br /> EU M—P <br /> ipePUMP Submersible! Turbine x Other NIA HP _ Pump Set ft Standing Water Level " <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> �Im OU ADVAN OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TRLE r DATE A/-19-2 0a C7 <br /> REQ MENT <br /> O <br /> R ?2 ?O2p <br /> (RUNM C��NT <br /> lit I <br /> DEPARTMENT U E ONLY <br /> Application Accepted By Date If 1Z C'Z 0 Area s /f a!' r Employee ID# L <br /> Grout Inspection By Date-S �I / I,- F SPECIAL Well Permit <br /> Pump Inspection By Data F WAIVER Received <br /> Soil Boring Inspection By D to Constructed W_elJ Depth r ft <br /> C�O/�1MENTS (iSf ( Pair@ t'/ 'P Cd�f�f�1CN IM� i!Y!_TWQII <br /> f11P3f1(ILf D!'t �uirt. �J <br /> PE 3C Received Check#/ Amount Dale Permit/ Invoice# Well 09Codes Info Cash Remitted Service Request# <br /> EH043-M 611114019 /( // 1T77FS0 7D WELL/Pt1Mr P[RMIT <br />