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CRoss STREET Yosemite Avenue APN 241—Q3 0 - 2-9 <br /> <br />PARCEL SIZE 4.9 ac LAND USE APPLICATION* <br />OWNER NAME Food Express (Kevin Keeney) PHONE 626-574-9094 <br />521 North First Ave Arcadia, CA, 98027 OWNER ADDRESS CITY /STATE/ZIP <br />CONTRACTOR Professional Services Industries (PSI) PHONE 714-484-8600 <br />CONTRACTOR ADDRESS 11980 Telegraph Road cimsrATErzip Santa Fe Springs, CA 90670 <br />SUBCONTRACTOR V & W Drilling, Inc. PHONE 209-469-7700 <br /> <br />SUBCONTRACTOR ADDRESS 1133 Blackhurst Drive <br /> <br />CITY/STATE/ZIP Galt, CA 95632 <br />LICENSE x C-57 U C-61 0 D-09 0 Other NUMBER 720904 EXPIRATION DATE 4/30/2022 <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - SiocKrori CA 95205 - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL (209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS lZEast Madruga Road cirrizip Lathrop, CA 95330 <br />DomEsTic WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochioropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring t Soil Sampling/Characterization <br />Public Water System <br />If ditferent from Owner: Water System Name Contact Name or Phone Number <br />TYPE Or WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />Monitoring Well(s) # of wells 0 Soil Boring(s) #01 borings Geotechnical 2 rod borings <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal El Cross-Connection Repair <br />New Pum • 0 Pump Replacement o Pump Repair 0 Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method X Mud Rotary 0 Air Rotary 1 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth 30 ft Excavation 8 in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br />in diameter / Conductor Casing Depth ft SA <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel Othe <br />Grout Seal Depth 30 ft t Neat Cement (94/b bag/5-10 gal water) 0 Sand Cement <br />Er Bentonite (20% solids) U Other PA <br />Grout Placement Method 0 Pumped 0 Free Fall Pi Other Tremie D Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 11 Pump Contractor 0 Other <br />CI Concrete Pedestal ODImensions: Width ft Length <br />Christy Box 0 Stove Pipe <br /> <br />It Thick <br /> <br />in <br /> <br />PUMP - ci Submersible 0 Turbine U Other HP Pump Set ft Standing Water Level <br /> It---- <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MININRINI 24 HOUR ADVANCE NO1 ICE REQUIRED FOR INSPECTIONS - PLEASE ('ALL (209) 953-7697 <br />0 Conductor Casing 96 VO 'don4lei 'peo e6rupew 1se9 Z9Z l DEPARTMENT USE ONLY <br />Applcation Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS Z- bori---cds <br />Date Area-3 / <br />Aro Employee 113;4 <br />Date 0 SPECIAL Well Permit <br />Date 0 WAIVER Received <br />Date Constructed Well Depth <br />PE <br />Codes <br />SC <br />Into <br />Received <br />Ay., <br />Check//I <br />Cash <br />Amount <br />, Remitted Date Permit/ <br />Service Request # invoice # Well ID# <br />4372 Is() /*--,,, /1_,,_ (c o i, 7.41gfri-- Irl(tio Livi 1 7_ <br />Pay 1 o12 <br />/6 / .7 3 ( <br />%Vert Pr PetmAt EHD043.06 10 21 2021