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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN- 1868 EAST HAZELTON AVENUE-STOCK-ON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS Sharpe Army Depot,850 Roth Road ci-vn.1P Lathrop/95231 <br /> S.Air ort Wa 198-02-001 351 A� <br /> CROSS STREET P Y API PARCEL SIZE NO USE APPLICATION Z: <br /> OWNER NAME Sharpe Army Depot PHONE <br /> OWNER AnoRess 850 Roth Road crtvlSTArFJZIP Lathrop/CA/95231 <br /> CONTRACTOR <br /> Middle Earth Geo Testing,Inc. PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 North Lemon Street Ci-'rISTATEIZIP Orange/CA/92867 <br /> SUBCONTRACTOR/CONSULTANT <br /> Mid Pacific Engineering,Inc. PHONE 916-927-7000 <br /> SL'BCONTRACTORICONSLLTANT ADDRESS 840 Embarcadero Drive CITYISTATH7JP West Sacramento,California 9560 <br /> LceNsE INC-57 D C-61 - D-C6 7:Other NUMBER `./ �" EXPIRATION DATE <br /> BILLING PARTY: ]OWNER ::CONTRACTOR 19 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)Z Dlbrornocnloropropane(4392)C Arsenic(4393) <br /> INTENDED USE C DomestlUPrtvate C InigatioNAgncultural O Industrial D Water Quality Monitoring =Sod Sampungichaacter¢ation <br /> 0 Public Water System <br /> if aiflerenl from Cwner vi sysi m Name Correct Name or PAona Number <br /> TYPE OF WORK C New Wail 0 Repiacemerr.Well �Well Alterabon/Mod,6cabon ❑Other <br /> 0 MonitoringWell s• #or wells D Soil Boring(s)s) a of Donnas a of boings <br /> (I 9( 0 Geotechrnwl <br /> Cut-Of-Service Well C Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> _ 0 New Pump O Punfll Re,lacement C.Pump Repair 0 Raise Well Cas27 _ <br /> WELL CONSTRUCTION <br /> DrillingMethod D Mud Rota 0 Air Rote C Auger D Cable Tool CPT-Cone Pentetrometer <br /> Rotary Rotary ug :.usn Point ❑ Omer <br /> Proposed Well Dapth50 fl Excavation 2 n diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter,) <br /> 0 Conductor Casing in diameter I Conductor Casing Depth R. <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched ❑Steel D Plastic Z Stainless Steel Other <br /> Grout Seal Depth 50 R XNeat Cement(94 Ib bag/5-10 gal water) :Sand Cement_ sack mmf7 gal water <br /> ❑Benlomte(20%solids) :Other <br /> Grout Placement Method CKPumped G Free Fall :Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller O Pump Contractor O Other <br /> 0 Concrete Pedestal ODlmensions Width fl Length R Thick M 0 Christy Box C Stove Pipe <br /> iI P _ :Submersible TUroine C Other _ HP _ Pump Set _ R 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 AN ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C PE ATIO LAWS. <br /> MIN 8 ' ft ADVANG CE REQUIRED FID <br /> p�j 11 4SPEC T 1 S-- II�EAk4g.CALL(209)953-7697 <br /> \'1 <br /> SIGNED TITLE rt lilm't+t' w�.•I 1Ia p�TE -t -21-2UZ U <br /> J <br /> I <br /> I <br /> I ( <br /> i I <br /> I I I I <br /> 1 I I I <br /> I 1 1 <br /> � --p'4YMFjV <br /> T <br /> CF <br /> i I <br /> --. Y22 ?020 <br /> COU <br /> DEPARTMENT U IE IN ME/yl" <br /> Application Acceptetl By L Dale '� ' Z 0 Area, Employee IDtt S - <br /> Grout Inspection By Date - SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Sod Boring Inspection By Si�ffj�j <br /> A 22 Date q/ —2-0 Constructed Wet[Depth h <br /> COMMENTS � <br /> PE SC Received Chock RemDined Date Perm <br /> Bes Invoice It ( Well ID# <br /> Codes Info <br /> l <br /> I I _ <br /> EHO<a.ps dtll:p,6 WELL RUMP PERMIT <br />