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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/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> w <br /> JOB ADDRESS 15299 Mckinley Avenue CITv0p Lathrop/95330 <br /> 198-060-19,198-010-44, D <br /> CROSS STREET E Louise Ave APN 198-010-45,&198-010-46 PARCEL SIZE 19.29 Acres LAND USE APPLICATION# o <br /> A <br /> m <br /> OWNER NAME Sam Gill PHONE N <br /> OWNER ADDRESS 865 Roth Rd Cm/STATE/ZIP French Camp/CA/95231 <br /> CONTRACTOR West Coast Exploration PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS P.O.Box 133 CITY/STATE/LP Escalon/CA/95320 <br /> SUBCONTRACTOR/CONSULTANT CTE CAL,INC. PHONE (209)543-1799 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Ave,Suite 150 CITY/STATE/7rP MODESTO/CA/95356 <br /> LICENSE 8 C-57 C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 1/31/2022 <br /> BILLING PARTY: OWNER _CONTRACTOR X SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED U Domestic/Private Imgalion/Agricultural Industrial - Water Quality Monitoring 9 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Omer. Water System Name Contact Name or Phone Number <br /> I <br /> TYPE OF WORK New Well Replacement Well L Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings sf Geotechnical 3 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal - Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair J Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ;5 Mud Rotary Air Rotary X Auger i Cable Tool Push Point Other <br /> Proposed Well Depth 15 It Excavation 4 inches in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad -i Steel -j Plastic Stainless Steel t I Other <br /> Grout Seal Depth �5- It {Neat Cement(94 lb bag/5-10 gal water) 3 Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) F!Other <br /> Grout Placement Method _ Pumped Free Fall `g Other Tremie It in Retardant/Accelerator name <br /> Installed By F Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in L:Christy Box 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 ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Ka,;-X i 15116 6zTITLE Staff Geologist DATE 7/30/2020 <br /> S E E A T T A C H E D <br /> cYMFN <br /> 03 20?0 <br /> C <br /> o 4JNry <br /> MINT <br /> DEPARTMENT VSE ONLY <br /> Application Accepted By G_ v� Date 3 aoa0 Area 3 L 464 Employee ID# s� <br /> Grout Inspection By Date 7 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By !z Date w Constructed Well Depth —ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permltl Invoice# Well IN <br /> Codes Info ash Remitted ervice Reg uest# <br /> SO 7---� <br /> EHG43-0o 6I11i2019 WELL(PUMP PERMIT <br />