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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/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 17831 McKinley AveCITY/ZIP p/ <br /> Lathrop/95330 <br /> 95330 m <br /> D <br /> CROSS STREET Vierra Rd. APN 198-150-08 PARCEL SIZE 32.79 LAND USE APPLICATION#N/A <br /> 0 <br /> A <br /> m <br /> OWNER NAME J.R.Simplot Company PHONE 209-858-6470 y <br /> OWNER ADDRESS 16777 South Howland Rd. CITYISTATE/ZIP Lathrop, CA 95330 <br /> CONTRACTOR Roadrunner Drilling&Pump Company, Inc PHONE 530-406-8559 <br /> CONTRACTOR ADDRESS 80 Bee Jay Way CITY/STATE/ZIP Woodland,CA 95776 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE x C-57 C-61 D-09 Other NUMBER 803909 ExPIRATION DATE 6/30/2021 <br /> BILLING PARTY: _OWNER X CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DOmestic/Private Irrigation/Agricultural X Industrial i I Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK X New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of weiis Soil Bonng(s) #of boongs Geotechnical #of bonnp <br /> Out-Of-Service Well Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary I Auger Cable Tool Push Point X Other Reverse <br /> Proposed Well Depth 285 ft Excavation 36"to so a z<"in Mamefer 9cs Open Bottom X Gravel Pack/Gravel Size SRI#8 in diameter <br /> X Conductor Casing 30 in diameter / Conductor Casing Depth SO ft <br /> Well Casing Diameterl 2.75 1-91)Thickness/Gauge/ASTM Sched 1/4" X Steel i Plastic Stainless Steel i i Other <br /> Grout Seal Depth 210 ft Neat Cement(94/b bag/5-10 gal water) X.Sand Cement 10.3 sack mixR gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller x 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 ft <br /> 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURREN ,AND ACT VE WITH THE CALIFOR CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WOR COMPEN TION LAW <br /> R A T REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN TITLE CFO DATE 3/27/2020 <br /> Ec MEN7' <br /> E/VED <br /> R 02 ?020 <br /> QU/N CO <br /> H�pARTM NTY <br /> DEPARTMENT USE ONLY ,[A� <br /> Application Accepted By Date L2 ZO Z n Area S ""1`° Employee ID# <br /> Grout Inspection By Date V 1 C o SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boning In ection By Date Constructed Well Depth ft/ f <br /> OMMENTS Lid t Le <br /> - <br /> Q 3 < d dfee t fe ► e <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted jjnfi e Re uest# <br /> 7 - o y�,� <br /> EHD 43-06 6/112019 WELL/PUMP PERMIT <br />