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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />JOB ADDRESS 18638 Somerston Parkway <br />Cry/ZIP <br />Lathrop, CA 95330 <br />CROSS STREET W Stewart Road APN 21021002 <br />PARCEL SIZE <br />LAND USE APPLICATION III <br />OWNER NAME Susan Dell'Osso 1g-. 1 ,/d' De i<iv vv-iLLL <br />PHONE 209-328-0630 <br />OWNER ADDRESS 73 W Stewart Road=f io utr,L. cj I <br />CITY/STATEZP <br />Lathrop, CA 95330 <br />CONTRACTORd <br />'� <br />PHONE� <br />CONTRACTOR ADDRESS 444-7�.srr vte4ey-RaAway <br />CITYrsTATEZP <br />I "thy ^&3-M <br />SUBCONTRACTOR Pitcher Drilling Co. <br />PHONE 209-879-7900 <br />SUBCONTRACTOR ADDRESS 218 Demeter Street <br />CITY/STATEZP <br />East Palo Alto, CA 94303 <br />LICENSE X C-57 C-61 D-09 Other NUMBER ExPIRATION DATE <br />DOMESTIC: WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agncultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different aam Owner. Water Syctem Name Contact Name at Phone Number <br />TYPE OF WORK Ci New Well Replacement Well -: Well Alteration/Modification Other <br />O MonitoringWells 0 of well 1 "01 bO""�s Geotechnical a of bo i <br />O �( Soil Boring(s) <br />C Out -Of -Service Well IOW -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method X Mud Rota Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 4 It Excavation � r+nl,1 in diameter Open Bottom Gravel Pac JGravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft X Neat Cement 194 11) bag,3-10 Qal waler) F Sand Cement sack mix77 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall A Other it ,,xn� (;? Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions. Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level It <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 AC VE WITH E CALIFO CON ORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMP SATION S. <br />MINI M 46 UR AD ENO EE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)) 9534697 <br />SIGNED TITLE JG� � �' `�t "�{ DATE ` /7?t) <br />a <br />M <br />�: <br />r <br />F✓oyQ��?018 <br />q��Fq <br />T , ANT, q4�H�Y <br />R <br />.DEPARTMENT USE ONLY ���/��//t <br />Application Accepted By Date � � Zi I �S Ares Employee ID* mm— <br />Grout Inspection By Dale +'SPE4CIA1111 Permit <br />Pump Inspection By Dale - WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS <br />END 47-05 rev.verf ctrl drtfl �/��� ��^ �f <br />4TU. 00 <br />WELL /PUMP PERMIT <br />d <br />