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WELL/PUMP PERMIT <br /> SAN JOAOUM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1568 EAST HAZELTON AVENUE-STOCKTON CA 95205- (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 18800 Christopher Way ClTrrnP Lathrop/W30 _ _ M <br /> Nestle Way -_ -_Apyi t98-130-350 PARCEL SIZE 9910 aC LAND USE APPLICATION•Government <br /> CROSS 8TREET — <br /> OWNER NAME City of Lathrop PHONE 209-941-7200 <br /> OWNER ADDRESS 390 Towne Centre Dmre _ _ _ Cr1Y/STA11f12JP Lathrop/CA/95330 <br /> CONTRACTOR n9 `"F~rtc --.--_.---_. PHONE <br /> CONTRACTOR ADDRESS CITYISTAtEMP <br /> SUBCONTRACTOR California Geotedn _ - _ _..- --_-- _ PHONE 831-634-1964 <br /> SUBCONTRACTOR ADDRESS 6886 Village Parkway .- - - --. _ _ CITY/STATEIIW Dublin.CA 94558 <br /> LICENSE X C-57 C-61 D-09 Omer NUMBER 812382 ExPMATION DATE QrJW020 <br /> Dommic WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromoc hloropropane(4392) Arsenic(4393) <br /> b77EN0E0 U8E Domestic/Private ImptiontAgncultural Industrial Water Quality Monitoring X Soil Samphng/Charadenzabon <br /> Public Water System <br /> If dieerent frau Omer WaNr Sytiern Name C nt d Name or PtNu MW <br /> Ybn OF WORK New Well Replacement Well Well AtteraboNModihcation Other <br /> Monitoring Wells) _ _ __•of wells Soft Boning(s) a of eon"a` X Geotechnical 3 a a eorviae <br /> Out-Of-Service Well Out-Of-Service Well Renewal Goss-Connection Repair <br /> New Pump I Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTIOII <br /> Drilling Method Mud Rotary I I Ax Rotary X Auger Cable Tod Push Pam Other <br /> Proposed Well Depth 8 Excavation _in diameter Open Bottom Gravel Pack/Gravel Size_- ....._in diameter <br /> Conductor Califl0 _in diameter / Conductor Casing Depth <br /> Well Cuing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other_- <br /> j Grout Seel Depth.. - 8 Neat Cement(94 ID bag/S-70 gal wafer) Sand Cement _ — - -.sack mix77 gal water <br /> Bentonite(20%solids) Other <br /> ,Grout Piscarrent Method Pumped X Free Fad Omer Retardant/Accelerator(name) <br /> r PEDESTAL Ittatalled By Driller Pump Contractor Omer <br /> Concrete Pedestal Dimaroions.Width_8 Length R Thick in Christy Box Stow Pipe <br /> 'Puisep - --- Submersible Turbine Other HP Pump Set fl Standing Water Level It <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDI CES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTTVI NoTHE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM N , S. <br /> MINI U A NCE NOTICE REQUIRED FtQft IN/SP.E/CJJI/ON�1S-PLEASE CALL(209)95 - 697 <br /> SIGNED T.I! Com/K C /L / DATE - <br /> PA <br /> P� 16 ?019 <br /> OgQUlfy C <br /> FOUNPy <br /> EZ t <br /> IftLJ_A MENT US 0/ / <br /> Application Accepted 8y �/ le r- Area_[//_� mP1 IDa <br /> Grout Inspection By __ Date SPECIAL We I PefTnll <br /> Pump Inspection By _ Date —�._(../�� WAfVER Received <br /> Sal Boring Ir---Rv Date _I Cgnstructed Well Depth _It <br /> COMMENTS �/y�� r _ �Lj• <br /> PE SC Received Chs•1 Amount- -- Dab Perm1U Invoice• Well ID• <br /> C Info OIL. Remkted Service Reques • <br /> Zd <br /> END 43M--W 4114118 WELL(PUMP PERMIT <br />