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21021001 <br /> PARCEL SIZE 92 tinID USE APPUCATION n/a <br />1DP Ve 1 prfler,PHONE 209-879-7900 <br />73 W. Stewart Road CITY/STATE/ZIP <br /> Lathrop,95330 <br />APN <br />P. 0. Box 133 <br />ENGEO <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />Escalon, 95320 <br />CITX/STATE/ZIP <br />PHONE 7605253944 <br />West Coast Exploration PHONE 209-985-7541 CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE XC,-57 <br />BILUNG PARTY: <br />17278 Golden Valley Pkw.N,L - L.rlyisrAnizip Lathrop, 95330 <br />NUMBER 870761 EXPIRATION DATE 1/31/2022 <br />SUBCONTRACTOR/CONSULTANT <br />W Stewart Rd uwmp Lathrop, 95330 JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />D-09 Ei Other <br />CONTRACTOR <br />C-61 <br />OWNER <br />Lakeside Drive <br />River Islands <br />If (Afferent horn Owner Water System Name Contact Name,, Phone Number <br />Out-Of-Service Well <br />New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) it of wells X Soil Boring(s) 5 sof bonngs X Geotechnical <br /> 5 Col bonngs <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />SIGNED <br />E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />D jrn_E Engineer ATE 3/15/2021 <br />17 <br />Lc_ Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />( • <br />Soil Boring Inspepion By <br />COMMENTS t t 1 <br />P <br />DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />TYPE OF WORK <br />Puree HP ft Pump Set fl Standing Water Level Submersible Turbine Other <br />in diameter <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter I Conductor Casing Depth ft <br />Retardant / Accelerator (name) <br />Well Casing Diameter in ThicknessiGauge/ASTM Sched Steel Plastic r Stainless Steel Other <br />Grout Seal Depth t 3 3 ft X Neat Cement (94 lb bag/5-10 gal water" Sand Cement <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped X Free Fall X Other tremie <br />Installed By Driller Pump Contractor <br />- Concrete Pedestal Dimensions - Wdth ft Thick <br />PEDESTAL Other <br />ft Length Christy Box Stove Pipe <br />sack cm /7 gal water <br />I HEREBY CER11FY THAT I HAVE PREPARED THIS APPUCAT1ON 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 UCENSE IS <br />CURRENT AND ACTIVE WITH THE CAUFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />S,4 <br />Date Si/ e:;/4.? <br />Date <br />Date <br />Date ;2/ <br />Crtef <br />Area S/ LeAti' Pr Employee ID* <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed NON Depth , ft <br />n13, e <br />DEPARTMENT USE ONLY <br />PE <br />Codes <br />SC <br />Into <br />Received Chec k*/ <br />Cash <br />Amount <br />Remitted Date , <br />Permit/ <br />Service RectuV* Invoice 0 Well ID* <br />Li3 1.1 ' SD A Z Vre_6(-- 4 / 34 t <br />3i t <br />eril'l VIP c"M N Li <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring 7 Soil Sampling/Characterization <br />7 Public Water System <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE • STOCKTON GA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />ENO 43-06 6/11/2019 e,ati 4 /2 2().s2371 <br /> <br />/22_2_3341.2J <br />WELL /PUMP PERMIT SS3210131/ 311S