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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT (:ALL (ZUU) ybS-fbUI FOR INSPECTIONS tAVIKtb I YEAR FROM UATE ISSUED <br />JOB ADDRESS 1695 East Louise Avenue CITYIZIP Lathrop/ 95330 <br />CROSS STREET McKinley Avenue APN 19810007 PARCEL SIZE 1.9 acres LAND USE APPLICATION # <br />OWNER NAME BP Louise Lathrop, LP PHONE (415) 497-1431 <br />OWNER ADDRESS 1129 Industrial Avenue, Suite 205 CITY/STATE/ZIP Petaluma, California 94952 <br />CONTRACTOR SalemEngineeringGroup, Inc PHONE (559) 271-9700 <br />CONTRACTOR ADDRESS 4729 W Jacquelyn Avenue <br />SUBCONTRACTOR Salem Engineering Group, Inc <br />SUBCONTRACTOR ADDRESS 4729 W Jacquelyn Avenue <br />LICENSE NC -57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP Fresno/CA/93722 <br />PHONE (559) 271-9700 <br />CITY/STATE/ZIP Fresno/CA/93722 <br />NUMBER 970772 EXPIRATION DATE 3/31/2024 <br />DoMEsTlc WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ® Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modlf'icatlon ❑ Other <br />❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings N Geotechnical 9 #of borings �C <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair / <br />❑ New PumD ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casino d i f GJ <br />VVtLL L UN51 KUU I IUN Sq <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other V 70 <br />Proposed Well Depth 10 to 50 ft Excavation 4" to 7" in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Sizerr I a <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft �EPq <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 1'D fe, SO ft ® Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ® Free Fall IN Other tremmie ❑ Retardant / Accelerator (name) <br />)EDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ftThick <br />1 ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Area 3 �1}n rd Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />?022 <br />T'4 � 7-y <br />47- <br />PE <br />Codes <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />z L Date <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />Date <br />Date CL <br />COMMENTS <br />Area 3 �1}n rd Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />?022 <br />T'4 � 7-y <br />47- <br />PE <br />Codes <br />SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Info Cash Remitted I Service uest <br />AMC TOV41M <br />EHDO43-06 04/07/2022 Page I o12 Well / Pump Pet -mit <br />