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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAxELTON AVENUE-STOCKTON CA 95205-6232(209)466-3420 <br /> NON-REFUNDABLE PERMIT www.sictaiii-cirld/eIrd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 3458 Yosemite Ave Cy/DD �Lathr 95330 <br /> 1Tm <br /> as <br /> CROSS STREET DArcy Pkwy APN 21440'009824140-010 PARCEL SlzEaa"Aar LANG USE APPLICATIONS _ S <br /> n <br /> OWNER NAME Lathrop Gateway 1,LLC PHONE r <br /> OWNER ADDRESS 450 Newport Center Drive,Suite 405 CITY/STATFJ2JP Newport Beads.CA 92660 <br /> CONTRACTOR Cornerstone Earth Group PHONE (408)245-4600 <br /> CONTRACTOR ADDRESS 1259 Oakmead Parkway CRYISTATFJLP Sunnyvale. (A 94085 <br /> SUBCONTRACTOR)CONSULTANT Middle Earth Geotesting,Inc. PHONE (714)633-5025 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 27639 1ndustri A BIW CrrY/STATFJZP Hayward.CA 94545 <br /> LICENSE x C-57 C-61 0-09 Other NUMBER 893'51 EXPIRATION DATE <br /> BILLING PARTY: OWNER K CONTRACTOR SUSCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General MineraUCWiform Bactena(4391) Dibromochloropropane(4392) ArseniC(4393) <br /> IKTEMM USE DomesticiPrivate ImgatcinlAgricullural Industrial Water Quality Monitoring x Soil Sampling"aradenzatlOn <br /> Public Water System <br /> If:.-r iN hen Ow,- W.HN Sy.—Nme CmIsd Hary w Phone NunEr <br /> Type Of WORK New Wall Replacement Wall Well Alteration/Modification Other <br /> Monitoring Wells) go! ells xSoil Bonng(s) 5 adti-rg. Geotechnical edlann4a <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pumti Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 7 Mud Rotary Art Rotary Auger Cade Tool Push Point s Other CPT Cone <br /> Proposed Well Depth 50-100' 0 Excavation 1.4- in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing--_in diameter / Conductor Casing Depth— —h <br /> Well Casing Diameter_in Thickness/GaugelASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth"..,J":`t- R x Neat Cement(94 1b DaW5-10 gal water) Sand Cement sack mixl7 gal water <br /> Bentonite(20%sokds) I, Other Boring backfilled with grout per county guidelines <br /> Grout Placement Method Pumped a Free Fait x Other or Tremie Retardant I Accelerator(name) <br /> Installed By Driller Pump Contractor Other <br /> Concrete Pedestal..Dimensions:Widthft Lenglr R Thick in Christy B . Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set h Standing Water Level h <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL 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 A D ACTIVE WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C MPENSATION <br /> MINI 48 DVANCE N CE REQUIRED �E 1 I S- LE{4SA/LE 3-76 <br /> SIGNED -� <br /> ' I <br /> pq V <br /> psi I <br /> REEF ANT <br /> APR 08 F� <br /> I I I I I I <br /> I IT R�vm <br /> tv <br /> VlN (/C <br /> A Ho vry <br /> PAR SENT <br /> I I I I <br /> i <br /> DEPARTMENT USE. ONLY <br /> Application Accepted BY Date / o Z` Area Employee IDu_' <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date ,s ,�n WAIVER Received <br /> Sail Boring Inspection By DaleLCff�ffLAW Constructed Well Depth R <br /> COMMENTS— --------------- <br /> PE SC Received CMdW Amount Date PMmig Invoice a Well IDs <br /> Codes Into Remitted Service Ra uest$ <br /> EKD4308 b1112d19 WELL/PUMP PERMIT <br />