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jr <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NVN-KEFUNDABLE PERMIT GALL (ZVU) y03-/b`J/ FOR INSPECTIONS IcAPIKt:J T TEAR FROM UA It: 155ULD <br />Joe ADDRESS 2956 W Stewart Road <br />c,TM,Z,P Lathrop. CA 95330 <br />CR05SSTREET Paradise Road APN 21325001 <br />PARCEL SIZE LAND SE APPLICATION # <br />///� <br />A <br />OWNERNAME Susan DellOsso L� O AX, <br />y��/��(��j,�// <br />&tAl HOVE11— 28-0630 <br />OWNER ADDRESS 73 W Stewart Road O �i6 jlIl!�IAtSTATEIDP <br />If <br />Lathrop, CA 95330 <br />CONTRACTOR <br />PHONE - - <br />CONTRACTOR ADDRESS <br />CITYISTATE/LP r-• <br />SUBCONTRACTOR Pitcher Drilling Co. <br />PHONE 650-328-8910 <br />SUBCONTRACTORADOREss 218 Demeter Street <br />CITYISTATE/ZIP East Palo Alto, CA 94303 <br />LICENSE X C-57 C-61 D-09 Other <br />NUMBER � ExPIRATION DATE -') I I <br />DoMEST1C WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If different I— Owner Water System Name Ccnlacl Name of Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells X Soil Bonngls) I q df bO1rgs Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />M of borings <br />Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 55 h Excavation `A I y%; -n in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter Thickness/GaugelASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft X Neat Cement (94 lb bag/5-10 gat wafer) Sand Cement sack mix17 gal water <br />Bentonite (20% solids] Other <br />Grout Placement Method Pumped Free Fall CherRetardant / Accelerator (name) <br />;PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions Width ft Length h Thick in Christy Box Stove Pipe <br />Pump Submersible Turbine Other HP Pump Set R Standing Water Level H <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 LAWP, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIV WITH THE CALIFO A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSKTION LAy1S. /� <br />MINIM 448 H96R ADV CE NOTIC QUIRED FOR INSPECTIONNS_ - PLEASE CALL 209)95 7697 <br />SIGNED TITLE ���"'� G"`C�ne'e'� DATE ` I <br />DEPARTMENT USE ONLY <br />Application Accepted By- Date y 2 i 6 <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Bonng Inspection By Date <br />COMMENTS <br />tioF�TN�N,Y <br />MFNT <br />Area E �ployee ID# V <br />SPECIALL We�IPerrnit <br />WAIVER Received <br />Constructed Well Depth ft <br />E»04346 1­ed4,14,18 ''//-7 /9 �31'� 60 <br />` 123`�LLL/ g � q0 oD <br />'HELL •'PUMP PERMIT <br />