Laserfiche WebLink
Mill! <br /> 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 16091 McKinley Ave CI y/ZIP Lathrop/95330 <br /> In <br /> CROSS STREET E Louise Ave APN 198-060-20 PARCEL SIZE 4.77 Acres LAND USE APPLICATION# o <br /> A <br /> m <br /> OWNER NAME Rafael Sandoval PHONE y <br /> OWNER ADDRESS 16351 S.McKinley Ave CITYISTATEZP Lathrop/CA/95330 <br /> CONTRACTOR West Coast Exploration PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS P.O.Box 133 CITY/STATEZP Escalon/CA/95320 <br /> SUBCONTRACTORICONSULTANT 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 670761 EXPIRATION DATE 1/31/2022 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural E Industrial I Water Quality Monitoring u Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK [I New Well _:Replacement Well Well Alteration/Modification ❑Other <br /> I MonitoringWell(s) #of wells SoilBoring(s) #of borings xGeotechnical 3 of borings <br /> i Out-Of-Service Well Out-Of-Service Well Renewal _ Cross-Connection Repair <br /> i i New Pump i Pump Replacement Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary Air Rotary X Auger i Cable Tool Push Point C Other <br /> Proposed Well Depth 15 ft Excavation 4 inches in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> t,l Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad F Steel :1 Plastic c Stainless Steel ❑Other <br /> Grout Seal Depth 15' ft x Neat Cement(94 lb bag/5-10 gal water) :1 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) a Other <br /> Grout Placement Method L Pumped C Free Fall x Other Tremie It in i Retardant/Accelerator name <br /> Installed By i Driller Pump Contractor 7 Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in i Christy Box i_ Stove Pipe <br /> PUMP ! Submersible_ Turbine 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 AI/� <br /> WORKERS COMPENSATION LAWS. <br /> MINIIM,U�M�,48,/HHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 � � <br /> SIGNED Azll/u[.tLli � GGT TITLE Staff Geologist DATE 7/30/2020 O <br /> 03�0�0 <br /> EE AT ACH4,/9, <br /> qRCoo <br /> N Ty <br /> r <br /> #ti <br /> TFFF <br /> 1111 1 1 1--ift <br /> DEPARTMENT U E ONLY <br /> Application Accepted By �-74�`y __ _ Date 3 D O Area 3 �D Employee ID# !`- <br /> Grout Inspection By_ __ Date SPECIAL Well Permit <br /> Pump Inspection By r Date �� WAIVER Received <br /> Soil Boring Inspection By ib lk!K �•` Date 2 / <br /> 1 _ r/.�_,1iV Constructed Well Depth ft <br /> COMMENTS <br /> PESC Received h Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash .Remitted S rvice Re est# <br /> ISO 76U 3 <br /> FIG A3-05 cn t0ly D /M6 ,/ )5 7 WELL/PUMP PERMIT <br /> .v <br />