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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 />RUN-KCFUNUA1%Lt rtKMI l L.ALL <br />ADDRESS 1700 E. Louise Ave <br />VO3-10VI FUR INbt tG IIUNS GArIKCA -1 rhAK FROM UAIt <br />STREET McKinley Ave APN 19814013 <br />G a1 El P & W <br />CITY/ZIP Lathrop / 95330 <br />SIZE 9.68aC LAND USE APPLICATION # <br />NAME ener ectrlc ower ater PHONE <br />ADDRESS 1 River Rd., Bldg 53 - 403e CITY/STATE/ZIP-Schenectady / NY / 12345 <br />vCTOR GEI Consultants, Inc. PHONE 916-631-4500 <br />Ii ADDRESS 2868 Prospect Park Drive, Suite 400 CITY/STATE/zIP Rancho Cordova / CA / 95670 <br />uTRACTOR Gregg Drilling & Testing, Inc. PHONE 925-313-5800 <br />4TRACTOR ADDRESS 950 Howe Road cITY/STATE/ZIP Martinez / CA / 94553 <br />E 2 C-57 D C-0 1 <br />1 -1 D-09 - Other NUMBER 485165 EXPIRATION DATE 1 r V l <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE - Domestic/Private -j Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 1K Soil Sam pling/Characterization <br />- Public Water System <br />If different from Owner. Water System Nam contact ame or one um r <br />TYPE OF WORK - New Well - Replacement Well U Well Alteration/Modification ❑ Other <br />_ Monitoring Well(s) # of wells X Soil Boring(s) 5 # of borings U Geotechnical #of borings <br />- Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />- New PumD - PUMD Replacement FI Pumo Reoair F1 Raise Well Casino <br />Drilling Method - Mud Rotary - Air Rotary X Auger r1 Cable Tool it Push Point F Other <br />Proposed Well Depth 20 It Excavation 8 in diameter 7 Open Bottom 7 Gravel Pack/Gravel Size in diameter <br />_ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 3 Steel ❑ Plastic 11 Stainless Steel ❑ Other <br />Grout Seal Depth 20 ft X Neat Cement (941b bag/5-10 gat water) U Sand Cement sack mix/7 gal water <br />- Bentonite (20% solids) ❑ Other <br />Grout Placement Method X Pumped D Free Fall ❑ Other Tremie tube U Retardant / Accelerator (name) <br />PEDESTAL Installed By L Driller U Pump Contractor Other <br />- Concrete Pedestal -Dimensions: Width ft Length If Thick in - Christy Box -1 Stove Pipe <br />PUMP - SubmersibleE Turbine ❑ Other HP Pump Set It 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED—— TITLEProjectProject Engineer DATE 4-28-2016 <br />fA <br />g <br />m <br />ro <br />w <br />DEPARTM ENT SE NL/Y- [RF'(� <br />�Application Accepted BDate /lJ Area 3WEmployee ID# -O 11,104 <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EHD 4306 WELL /PUMP PERMIT <br />4/30/12 <br />