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PHONE LodiCRY/STATE/ZIP CA 95240 N/A EXPIRATION DATE 5/31/2023 Other 669004 NUMBER 980E Louise Ave Lathrop 95330 JOB ADDRESS CITY/ZIP SUBCONTRACTOR/CONSULTANT ADDRESS N/A CITY/STATE/ZIP CITY/STATE/ZIP OWNER NAME OWNER ADDRESS CONTRACTOR 01 )9 Dex",.5 Ve- A5P/R001 PP3p-e11es ETC, ApN 19812011 CROSS STREET _ Cambridge Neil 0 Anderson: A Terracon Company PARCEL SIZE 70 ac LAND USE APPLICATION # PHONE tc,(4ette CA c1q5q19 PHONE 209-367-3701 CONTRACTOR ADDRESS 902 Industrial Way SUBCONTRACTOR/CONSULTANT N/A N/A LICENSE 7C-57 BILLING PARTY: C-61 D-09 _ OWNER _ CONTRACTOR SUBCONTRACTOR/CONSULTANT Public Water System If different from Owner: Water System Name Contact Name or Phone Number WELL CONSTRUCTION Drilling Method iMud Rotary _ Air Rotary /Auger _ Cable Tool Push Point _ Other Proposed Well Depth ft Excavation in diameter _ Open Bottom _ Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other Grout Seal Depth 210- ft /Neat Cement (94/b bag/5-10 gal water) _ Sand Cement sack mix/7 gal water Bentonite (20% solids) Other Grout Placement Method _ Pumped X Free Fall X Other t Y ew _ Retardant / Accelerator (name) ft Thick Other ft Length in _ Christy Box _ Stove Pipe PEDESTAL Installed By Driller Pump Contractor _ Concrete Pedestal _Dimensions: Width ft Pump Set ft Standing Water Level PUMP HP _ Submersible_ Turbine _ Other NA41-1512g { WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 NON-REFUNDABLE PERMIT WWW.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392)1 Arsenic (4393) INTENDED USE Domestic/Private _ Irrigation/Agricultural _ Industrial _ Water Quality Monitoring 'Soil Sampling/Characterization _ New Well _ Replacement Well - Monitoring Well(s) # of wells Out-Of-Service Well New Pump Pump Replacement _ Well Alteration/Modification _ Other _ Soil Boring(s) # of borings ( Geotechnical Out-Of-Service Well Renewal Cross-Connection Repair Pump Repair Raise Well Casing I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIM 8 DVANCE NOTICE QUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 TITLE C7ratAP Alt4 i DATE 1 1/1 // Empriimmimpommu E.' 4, , renim,”iiim..-- . qi .. "....... ., ,••:.... r ha , .- - i ,Iiiiimi.imun ,orliroircir Iri ,Vik " mr-o , .„. --,•L, .",.. 0.: t Of r2 .' _2 . ..... , • •• ,.- ',,....., - , . ' • , . 4r ,S, II 4.- .4,.. . IN ' -, _. -. . -. - , . I a UI ._ . 17-- , If 0 r VII *V • ,•- !I , u . umwomil! •••UUUULL&.L1JUU _•3-- 1 i viiiiiiiv\ut D UUUUUUUUUUUUUUU IN LIA441ll LUMEN 4 . . ..,..„,-.u....k. . ,--,.• 111111111111111111111• UI • U. i MEM . ILIVIINTIVAECNT . - SIGNED TYPE OF WORK # of borings :SS321CICIV 3119 Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS DEPARTMENT USE ONLY 11/0.7 /42 Employee ID# Ac SPECIAL Well Permit WAIVER Received Constructed Well Depth ft Area 3 Leftliro Date Date Date Date PE Codes SC Info Received Check#/ Amount Remitted A Date Permit/ Service Request # Invoice # Well ID# I-i3-7 ISO 43..y,y 2.12 27711/n I i 1 6 II 2 -1 L v\IPODLI 7/ IA EHD 43-06 6/1112019 WELL /PUMP PERMIT