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a <br />c� <br />WELL/PUMP PERMIT <br />SAN Jo.ADUW COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCX7ON CA 95206 6232 (209) 468.3420 <br />IVUIV-KEtUNUABLE PERMIT www.slgov.orgreno tAYlKr-b 1 TEAR FROM UATE ISSUEL <br />JOB ADDRESS 120130 SyHjarlan Rd cmrb, Lathrop, 95330 <br />CROSS STREET N/A API 196-030-280-000 PARCEL SQE 3.6 ac LAND USE APPUCATION 9 <br />OWNER NAME RM(' <br />Fntpmri����� PHONE <br />OWNER ADDRESS 3736 Fallon Road #410 CRYISTATEMPnLibinCA��S <br />CONTRACTOR Comerstone Earth Group PHONE (408) 245-4600 <br />CONTRACTOR ADDRESS 1259 Oakmead Parkway CrTYISTATEIZJP Sunnyvale, CA 94085 <br />SUBCONTRACTORICONSULTANT FYDloratinn r t-nzPrVICPC Inc PHONE, (40 8) 483-9026 <br />SUBCONTRACTORICONSULTANTADDRESS 1535 Industrial Avenue CITY/STATEIZIP an Jose CA 9112 <br />LICENSE X. C-57 : C-61 D-09 Other NUMBER 484288 ExP1RATION DATE 3 a <br />BILLING PARTY: !j OWNER XCONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPUND: ; ; General Mineral/Coliform Bacteria (4391) .- Dibromochloropropane (4392) i Arsenic (4393) <br />INTENDED USE E DornestiC/Privote ImpationlAgnadturol : Industrial : Water Quality Monitonng X Sod SanpinglCharacteraation <br />D Public caster System <br />If d7erem nom 0_., Water system came contact Name w Phone N—iu r <br />"OF WORK Naw Wel -: Replacement Well - Wall AlteratiomModifmation Other <br />❑ Monitoring Wel(sl S of wells XSod Bonng(s) _ 4 a i I Gootaehnieal a apt^7e <br />U Out -Of -Service Well :) Out -Of -Service, Well Ronovral :' Cross -Connection Repair <br />U New Pump : 1 Pumo Redaeement '' Pumo Rewir Raise Well Casino <br />Drilling Method U Mud Rotary :: Air Rotary X Ager U Cable Tool I1 Push Point , i Other <br />Proposed Wdl Depth 20-40 R Excavatron 8 in diameter I: Open Bottom :i Gravel Pack/Gravel Sao in diameter <br />Conductor Casing in diameter I Cenductvr Casing Depth R <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel f; Plastic - Stainlosa Steel t Other <br />Grout Seal Depth J03 - 4'J R X Neat Camont (94 lb be915- fO gal water) rl Sand Cement sack mixr7 gal wntar <br />Bentonite (20% solids) X Other Borings backfilled with grout per county guidelines <br />Grout Placement Method Pumped XFree Fag 4 <br />Other Dr I remie Retardant I Accelerator (name) <br />PEDESTAL Installed By '.: Driller I I Pump Contractor rOther <br />:: Concrete Pedestal ❑DImenslons: Wdih It Length R Thick in Christy Box 7 Stove Pipe <br />P M :: Submersible': Turbine : Other HP Pump Sat R Standing Water Level ft <br />I HEREBY CERTIFY THAT AVE P EPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAOUIN COUNTY ORd NCE TE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND AC TH "TIE <br />CONTRACTORS STATE UCENSE BOARD AND THAT I AM IN COMPLIANCE TH ALL <br />WORKERS C , PE SA N WS. <br />r,11FiI'',1 46 Ili A A?JCE NO I(:E. REQUIRED F C' ' JN' <br />SF"' IIOS i'I EASE CALL <br />A(ZJ9 t i' <br />SIGNED TITLE A.% rZ <br />DATE <br />DEPARTMENT USE ONLY <br />r T <br />Application Accepted By �— Date S 4C �/ <br />Grout Inspection By Data <br />Pump Inspection By Date <br />Sol Boring Inspection By Date <br />COMMENTS <br />[tt1r< <br />Area Employee IDs As <br />SPECIAL Well Permit <br />I l WAIVER Received <br />Constructed Well Depth R <br />y <br />m <br />D <br />S <br />rn <br />u <br />u <br />EH04-10d e/ItR019 MELL!PUMP PERNAT <br />)2—rS5312EcTZ39-79 <br />UTIVITITZ <br />EH04-10d e/ItR019 MELL!PUMP PERNAT <br />)2—rS5312EcTZ39-79 <br />