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• i� 4fr1o. �� �- IZ OSS". �Kfir►.w�-o�. # b l 4440`•1 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 /> N <br /> Joe ADDRESS 3637 W Stewart Rd(South of Cohen Road) CITYIZIP Lathrop, CA, 95330 m <br /> 0 <br /> CROSS STREET Para d:ze Road i Cohen Road APN 21322001 to 004 PARCELSVE 535 LAND Use APPLICATION# _ m <br /> 21331031 acres <br /> OWNER NAME Susan Dell'Osso / �,/a-(,(�S} PHONE 209-879-7900 <br /> OWNERADDRESS 73 W. Stewart Road/ZQ4 � CITYISTATEIZIP a — <br /> CONTRACTOR California Push Technologies, Inc. PHONE 510-357-3677 <br /> CONTRACTOR ADDRESS 820 Aladdin Avenue CITYISTATrIZIP San Leandro, CA, 94577 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 8842,27 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X 37.807954` Y -121.342948 Township_ Range Section_ <br /> INTENDED USE Dome511C,POVate IrtigatwniAgricu!tural Industrial Water Quality Monitoring X Soil SamplingtCharacterization <br /> Public Water System <br /> if difteri'm from OWPI er yxem —e or ameor ne um i <br /> TYPE OF WORK New Well - Replacement Well - Well Alteration/Modification _Other <br /> Yol oonrgs <br /> Monitoring Wells) #of wells Soil Bormg(s) a or bonngs X Geotechnical 11 <br /> Out-Of-Service Well Oul-0f-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Weil Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Y. Push Point Other <br /> ProposedWell Deptn30 to 10(h Excavation 2 in in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness%Gauge'ASTM Schad Steel _ Plastic Stainless Steel Other <br /> Grout Seal Depth 30 to 100y X Neat Cement(94 lb bag45-10 gal wafer) Sand Cement sack mix,7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped Free Fall Other Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By Dryer Pump Contractor Other <br /> Concrete Pedestal Dimensions Width It Length h Thick in Christy Box Stove Pipe <br /> Pure Submersible Turbine Other HP Pump Set ft Standing Water Level h <br /> 1 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 HQUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TiTLEStaff Engineer DATE 3­41-1 1 <br /> El QED <br /> 2017 <br /> e IN COu <br /> kT <br /> 3/ /vim MENT U E NLY <br /> Application Accepted Bye. �'// _ _ to __ Area C` mployee ID# a-" <br /> Grout Inspection By EEEY77 Date SPEC AL Will Permit <br /> Pump Inspection By Date _ WAIVER Received <br /> ( <br /> see(,+ 0 n Soil Boring Inspection By 7 Date Constructed Well Dept ft <br /> COMMENTS L3tan',":r--s.— le <br /> 31231 J�- PE SC Received CheclaY/ Amount Date Permit) Invoice Well IDN <br /> Codes Info 8 ash Remitted Service Request <br /> M <br /> l i 3 110 DO m <br /> ENC 43-:b � WELL/PUMP PERMIT <br /> 4'301_ <br />