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JOB ADDRESS s3-63rm IgSS-1 CPueirbio aria, Lathrop 95330 <br /> <br />CROSS STREET -Schernerel-084t-Roael ino p1 theXpN 24102062 PARCEL SIZE 6.23 Ac LAND USE APPLICATION # <br />209-465-5883 PHONE <br />235 East Weber Avenue, PO Box 1461 Stockton, CA 95201 CITY/STATE/ZIP <br />ENGEO Incorporated plioNE 209-684-7615 <br />CONTRACTOR ADDRESS 17278 Golden Valley Parkway crryisTATErzip Lathrop, CA 95330 <br /> <br />916-799-8198 GEO-Ex Subsurface Exploration SUBCONTRACTOR PHONE <br />Dixon, CA 95620 CITY/STATE/ZIP <br />4267 LICENSE x C-57 C-61 D-09 Other NUMBER 95 EXPIRATION DATE 07-31-2022 <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />Reclamation District No. 17 <br />1510 Madera Dr SUBCONTRACTOR ADDRESS <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool x Push Point <br />2 inches in diameter <br />Other <br />Proposed Well Depth 100 ft Excavation Open Bottom Gravel Pack/Gravel Size in diameter <br /> <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 100 ft X Neat Cement (94 lb bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other <br /> <br />Grout Placement Method X Pumped Free Fall Other Retardant I Accelerator (name) <br />sack mix/7 gal water <br />ft Thick <br />Other <br />ft Length in Christy Box Stove Pipe <br />PEDESTAL Installed By Driller Pump Contractor <br />Concrete Pedestal Dimensions: Wdth <br />PUMP Pump Set ft Standing Water Level HP ft Submersible Turbine Other <br />sAi <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STocKToN CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPUNG: 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 :SSMIOCIV 31.1S New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump Pump Replacement <br />Well Alteration/Modification Other <br />Soil Boring(s) of borings <br />X Geotechnical 8 h ot borings <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />Pump Repair Raise Well Casing <br />TYPE OF WORK <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 />IAINIMUMI8 HRUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED WW1/1/11 ••• TITLE Staff Engineer DATE 03/08/2021 <br />ONLY <br /> <br />Application Accepted By --- Z."-- Date 7 Area y95 <br />Grout Inspection By A Date SPECIAL Well Permit <br /> <br />Pump Inspection By Date WAIVER Received <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Checkft/ <br />ACash <br />Amount <br />Remitted ate Permit/ Invoice # Well ID# <br />4372 ) cCi lei_ 030-- P I gol0 ;1 i4 pervice tqq7e 9st# <br />VIT OOV -1 <br />DEPARTMENT USE <br />Employee ID# As <br />Constructed Well Depth ft <br />/-2-/e4 zwo EHD 43-06 reseed 4/14/18 WELL /PUMP PERMIT