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CROSS STREET McKinley Ave APN PARCEL SIZE 611 LAND USE APPLICATION it <br /> PHONE <br />Ow/STATE/Zip Lathrop/CA/95330 <br />pHomE 209-985-7541 <br />Rafael Sandoval OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />16351 S McKinley Ave <br />West Coast Exploration Inc <br />CONTRACTOR ADDRESS 'O Box 133 <br />SUBCONTRACTOR/CONSULTANT CTE Cal Inc <br />SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Ave Ste 150 <br />oryisTATEme EscalondCA/95329 <br />FamoNE 209-543-1799 <br />Cirr/STATE/Zr ModestoiCA/95356 <br />En,,EATI,E DATE 1/31/2022 LICENSE It2.57 7.61 c] D-09 S Other NUMBER 870761 <br />0 CONTRACTOR ii SUBCONTRACTOR/CONSULTANT BILLING PARTY OWNER <br />0 <br />WELL/PUMP PERMIT <br />SAN J °AMIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST Hazti TON AVENUE - STOCKTON CA 95205-6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT WWw.sigov oehd EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 2031 E Louise Ave oryop La1N•op/.95330. <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392): Arsenic (4393) <br />INTENDED USE Domestic/Private 7. Irrigation/Agricultural Industrial 7.; Water Quality Monitoring 3 Soil Sampling/Characterization <br />Public Water System <br />if deferent from 0.ner Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well _ Replacement Well 7. Well Alteration/Modification Other <br />2 Monitoring Well(s) e of wells 2 Soil Boring(s) t of temp It Geotechnical 1 I of bonne, <br />.: Out-Of-Service Well ._ Out-Of-Service Well Renewal L: Cross-Connection Repair <br />I New Pump - Pump Replacement -• Pump Repair 2 Rase Wet Casing <br />WELL CONSTRUCTION <br />Drilling Method . Mud Rotary E: Air Rotary B Auger Ei Cable Tool L2 Push Point 5 Other <br />Proposed Well Depth 10 ft Excavation 4 'riches in diameter 9 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Demeter in Thickness/Gauge/ASTM Sched 0 Steel 5 Plastic 2 Stainless Steel I Other <br />Grout Seal Depth 10 ft M Neat Cement (94 lb bag15-10 gel water) = Sand Cement deck mix/7 gal water <br />= Bentonde (20% solids) = Other <br />Grout Placement Method -1 Pumped S Free Fall 0 Other - Retardant/ Accelerator (name) <br />PEDESTAL Installed By 7 Driller 2 Pump Contractor 2 Other <br />. Concrete Pedestal _Dimensions Width ft Length ft Thick Christy Box ._ Stove Pipe <br />PUMP Submersible_ Turbine 7 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 />SiGNE0 /eafrnalogi C5/62.60104E• ymi Staff Geolog St DATE 2/12/2021 <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL. (209) 953-7697 <br />A <br /> <br />A <br />FFB <br />WENT <br />1 <br />REC <br />SAN JCLAQU <br />ENV, R <br />N t1NTY <br />ME. A— <br />N ON <br />DE.1-93:N. ME <br />DEPARTMENT USE <br />Application Accepted By...?-----'---ZZ--"/— Date <br />Grout Inspection By -Sin S3/(k1('7,./1_..--- Date <br />Pump Inspection By Date <br /> <br />Soil Boring InApection By , Date <br />COMMENTS I ( C, I NJ nONniCt 'kr e n L. Dc In ft, r ee'l , lie rvi <br />--.1 I <br />Area <br />L <br />Employee IDIt A5 <br /> <br />SPECIA L Permit <br />WAIVER ReCelVed <br />ft Constructed Well Depth <br />r, • L. (71 <br />ONLY <br />A <br />PE <br />Codes <br />SC <br />Info <br />Recoil <br />y <br />Checked <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Seirteg tequest A n Invoice # Well iCe <br />itch-.i 1 `.. ri i2192/161 49 S-C, tt-1V II VW UV9 111))( <br />EH043-06 BiIONi9 <br /> WELL/PUMP PERMIT