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DncuSign Envelope ID: E57A3176-2FC3-4OA3-8F2E-3CE640FE53F5 <br />1 WELL/PUMP PERMIT <br />S}AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT CALL (209 j 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br />JOB ADDRESS 11293 S Manthey Rd <br />CFTY21P Lathrop/95330 <br />CROSS STREET Roth Rd APN 191-25-014 PARCEL SIZE 114A— LAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />Gurbinder Sin h S 1 ✓f h Rif, / _171 Vr To -e it ft .. PHONE408-355-570017900 Murphy Pkwy CITY/STATE/ZIP Lathrop/CAi95330 <br />CONTRACTOR West Coast Exploration Inc <br />CONTRACTOR ADDRESS P.O. Box 133 <br />SUBCONTRACTOR CTE CAL Inc <br />SUBCONTRACTOR ADDRESS 4230 Kieman Ave Ste ISO <br />PHONE 209-985-7541 <br />CITY/STATE1ZIp Escalon/CAi95320 <br />PHONE 209-543-1799 <br />CrrylSTATEIZIp Modesto/CA195356 <br />LICENSE * C-57 LI C-61 D-09 ..1 Other NUMBER 870761 EXPIRATION DATE 1/31!2024 <br />DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE = Domestic/Pnvate �] Irrigation/Agricultural Industrial C Water Quality Monitoring 10 Soil Sam pfinglCharacterization <br />Public Water System <br />jIf different from Osmxr Water SWem Name Contact Name or Phone. Number <br />TYPE OF WORK New Well I: Replacement Well ❑ Well Atteration/Modrfication Other <br />Monitonng Well(s) # of wells ❑ Soil Boring(s) 4 of aonngs r Geotechnical 6 <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />L New Pump A, Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ii Mud Rotary ❑ Air Rotary * Auger Cable Tool :1 Push Point F! Other <br />Proposed Well Depth 30 _ft Excavation 4 inches in diameter l Open Bottom i ! Gravel Pack/Gravel Size_ <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />r <br />m <br />D <br />v <br />0 <br />M <br />w <br />1—A y 'L T' <br />#ofboCEC <v —1) <br />AUG" p <br />L_ <br />SAN JOAQUIN C UNT1 <br />Ake L <br />"'NIT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic ❑ Stainless Steel 7 Other <br />Grout Seal Depth Sy ft n Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixl7 gal water <br />J Bentonite (20% solids) Other <br />(Grout Placement Method , Pumped !R Free Fall n Other Retardant / Accelerator (name) <br />PEDESTAL installed By Driller : ; Pump Contractor C Other <br />Ll Concrete Pedestal .,Dimensions: Width ft Length ft Thick <br />lin ; i ChristyBox :1 Stove Pipe <br />Pump =1 Submersible Turbine a Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the egad 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 wetis or surface water within 200' radius of proposed well. <br />NH.NINIUNI 24 HOUR ADVANCE NOTICE REQUHZED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Jf� `— Z— Date ,Pq �.4 <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By -� Date L Z Z <br />COMMENTS <br />Area / Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />It <br />PE SC Received Check#/ <br />Codes Info B C h <br />Amount Pernritl <br />Remitted Date ervice 13uest # Invoice # Well ID# <br />EHU043A604/072022 � ,� /J � ���� � C � � % P�� f�/�. �l� R'e11/ I'utp Pumt <br />