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Y <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468.3420 <br />Sc Received <br />Info <br />NON-REFUNDABLE PERMIT www.sigov_.orr/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />Date <br />,JOBADDREss Barbara Terry Blvd and Stanford Drive ciryizIP Lathro , CA <br />m <br />ICR6SSSTREET Stanford Drive_____ ___. _ APN 19203049 PARCEL SIZE 17.84 LAND USE APPLICATION <br />$7co <br />OWNER NAME Lathrop Land Aquisition LLC <br />m <br />PHONE <br />OWNER ADDRESS 303 Dolphin Drive #600 CITY/STATE/ZlP Redwood City, CA 94o65 <br />CONTRACTOR Middle Earth Geo Testing PHONE 714:.633-5025 <br />_ <br />iCONTRACTOR ADDRESS 954 N Lemon Street CA 22867 <br />- -- CITYISTATE/ZIP_ Orange, <br />(SUBCONTRACTOR/CONSULTANT Mid Pacific Engineering, Inc. 916-662-0909 <br />..._ _ <br />PHONE <br />SUBCONTRACTOR/CONSULTANTADDRESS 84o Embarcadero Drive, Suite 20 CITY/STATEIZIP W. Sacramento Ca 9.5_5o5 <br />LICENSE 9 C-57 C C-61 C D-09 C Other NUMBER 899451 EXPIRATION DATE6 0 20Nui 3 <br />BILLING PARTY: ❑ OWNER ❑ CONTRACTOR ;K SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE 0 Domestic/private C Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well 0 Replacement Well C Well Alteration/Modification ❑ Other <br />0 Monitoring Wells) # of wells 0 Soil Boring(s) # of borings ❑ Geotechnical 3 # of borings <br />C Out -Of -Service Well C Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />0 New PumL. ❑ Pump Re.dacement C Puml. Reuair ❑ Raise Well Casing <br />WELL CONSTRUCTION —. <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool jL( Push Point 0 Other <br />_ <br />i Proposed Well Depth SO ft Excavation _ 2 in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched j Steel 0 Plastic :� Stainless Steel 0 Other <br />Grout Seal Depth "b it <br />;KNeat Cement (94 Ib bagl5-10 gal water) C Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) C Other <br />Grout Placement Method ,K Pumped ❑ Free Fall 0 Other❑Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal ❑Dimensions: Width ft Length _ ft Thick in 0 Christy Box C Stove Pipe <br />I <br />PUMP _ ❑ Submersible❑ Turbine 0 Other HP Pump Set__ ft Standing Water Level ft <br />III <br />_ _ <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION <br />AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY LACES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTI <br />WI H THE CALIF RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSA N f,P,VUS. <br />MINIMUM 48 H2�C�iLANC TICE REQUIRED FOR INSPECTIONS <br />SIGNED <br />-PLEASE CA/LL (2G9) 9553-7697 <br />TITLE CL1'I't ��(.ttST/ .� t�.� GtYlGi -IZiY DATE (.[� `JO'2 L <br />I <br />i <br />> U E N A k 1 M t N I U J t U N L Y <br />Application Accepted By � 7 --Z Date 7 C/ ,.? AreaGei�� ro Employee ID# A( <br />Grout Inspection By Date 2, 2 ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />11 <br />PE <br />Codes <br />Sc Received <br />Info <br />Check#/ Amount <br />Cash Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Request # <br />437a <br />so <br />$7co <br />ZI <br />P <br />EHD 43-06 6/11/2019 *4k <br />YWELL /PUMP PERMIT <br />s '(// <br />