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r 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 /> JOB ADDRESS 1500 Madruga Rd CITYIZIP Lathrop/95330 m <br /> CROSS STREET Guthmiller Rd APN 241-030-35 PARCEL SIZE 3 Acres LAND USE APPLICATION# o <br /> OWNER NAME Rafael Sandoval PHONE <br /> OWNER ADDRESS 16351 S.McKinley Ave CITv/STATE/ZIP Lathrop/CA/95330 <br /> CONTRACTOR West Coast Exploration PHONE(209)985-7541 <br /> CONTRACTOR ADDRESS P.O.Box 133 CITY/STATE/ZIP Escalon/CA/95320 <br /> SUBCONTRACTOR/CONSULTANT CTE CAL,INC. PHONE(209)543-1799 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Ave,Suite 150 CITY/STATE/ZIP MODESTO/CA/95356 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 1/31/2022 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X 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 Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Sail Boring(s) s of borings X Geotechnical 2 #of bodngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary XAuger I Cable Tool Push Point I Other <br /> Proposed Well Depth 15 ft Excavation 4 inches in diameter i Open Bottom 11 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic I Stainless Steel Other <br /> Grout Seal Depth js ft X Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall XOther Tremie It in Retardant/Accelerator'name <br /> IPEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other 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 COMPENSATION LAWS. <br /> MINIMUMMM�48 HOUR ADVANCE <br /> �NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ,`"^"'�Q� ""�^""""'� TITLE Staff Geologist DATE 7/22/2020 <br /> S E E A T T A C H E D <br /> Pq yM�N <br /> ECFV AFD <br /> 28 2020 <br /> l RONMEC�UNTY <br /> DEpA TMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area S&AIOP Employee ID# y <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Co strutted Well Deptlll ft <br /> COMMENTS _� _SIC e_ GVH tl..� �I4 /o-r �h. <br /> PE SC Received Check#/ Amount I Date Permit/ Invoice# Well ID# <br /> Codes Into ash Remitted Service Re nest# <br /> 3l ;0V/5,0- �4 INN U <br /> EH043-06 6/1112019 ///� ^���� WELL PUMP PERMIT <br />