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Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well 0 Replacement Well a Well Alteration/Modification 0 Other <br />'fro (rat? el <br />WEU 'PUMP PERMIT EHD 43-06 6/11/2019 Over rad <br />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.slg ov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: 0 General IVlineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) 4 of borings / Geotechnical 1 e at b°4"" <br />0 Out-Of-Service Well C Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method it Mud Rotary 0 Air Rotary IX Auger C Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth 50 ft Excavation 8 In diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth 50 ft tit Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix17 gal water <br />0 Bentonite (20% solids) C Other <br />Grout Placement Method 0 Pumped CI Free Fall f4 Other tremie C Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal ODImensions: Width ft Length ft Thick in 0 Christy Box C Stove Plpe <br />0 Submersible 0 Turbine C Other HP Pump Se 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 />MINj1 <br /> .4/ <br />UM H ....A.DVANCE NOTICE REQUIRED FOR INS ECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br /> , <br />TITLE c/h/v;T D 7, /2 / ATE <br />Application Accepted By ..---/Z Z-1-- Date 347 X <br />Grout Inspection By h c'y."--,- Date <br />Pump inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS 0_1,11+1 ti# / e'S-S1 c 13 r i s tor)" Ce le4 CV- <br />DEPARTMENT USE ONLY <br />a 1 SS31100V 3.LIS - 1 <br />4 <br />:•,..,* • ...._____-___ ---- ---- — , ---- —..-- ... <br />I --.. -s .. <br />“..) 11.11111 • _ _ <br />Y /, ,--, ......,.... Ill II Iir , <br />''.. 1,....” ... ••uiuuu <br />trz....:=1 :WSW <br />ii <br />=MI <br />. W.:1W. :"1.7... <br />........ --"—•—•" .... TRIMINES - NM <br />, - , Iiii ii , <br />ii a En" <br />U••IUUU <br />SAN JOA <br />,• \ • MI ENVIF <br />...s ___ ...., ..• ME iiii <br />. .I.TH <br />--- i • <br />.,, NM I <br />,n4lier MN <br />Area 3 &AO" Employee ID* AS <br />7. PECIAL Well Permit <br />= WAIVER Received <br />Constructed Well Depth ft <br />I PE <br />Codes Info I 5 Cash Remitted <br />“"0 HiT 7.2 lc° <br />Permit/ Invoice # Well ID# <br />KM • rt_ <br />Service Re :Liu; <br />SC r Received ; Check#/ Amount Date <br />MENT <br />EIVED <br />2 3 2021 <br />QUIN COUNTY <br />ON MENTAL <br />DEPARTMENT <br />CITY/STATE/ZIP Galt/CA/95362 <br />JOB ADDRESS Christopher Way CITY/ZIP Lathrop/95330 <br />1133 Blackhurst Drive CONTRACTOR ADDRESS <br />Mid Pacific Engineering SUBCONTRACTOR/CONSULTANT PHONE 916-516-2113 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 840 Embarcadero Drive, Suite 20 CITY/STATE/ZIP West Sacramento,CA, 95605 <br />LICENSE V C-57 0 C-81 C D-09 0 Other <br />BILUNG PARTY: 7 OWNER <br />NUMBER 720904 EXPIRATION DATE 4/30/22 <br />0 CONTRACTOR SUSCONTRACTOR/CONSULTANT <br />APN 198-130-59 <br />City of Lathrop <br />390 Towne Center Drive CITY/STATE/ZIP <br />V&W Drilling Inc. <br /> PARCEL 515511 LAND USE APPLICATION # <br /> PHONE <br />Lathrop/CA/95330 <br />PHONE 209-369-9600 <br />CROSS STREET Darcy Parkway <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />NTENDED USE 0 DomestIc/Private C Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ic Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner.