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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 /> JOB ADDRESS 3379 North Tracy Boulevard CITyrbp Tracy/95376 T <br /> D <br /> CROSS STREET Clover Road APN 21416021 PARCEL SIZE 0.67Acfe LAND USE APPLICATION# o <br /> OWNER NAME IJ Remainder LLC cc Meltzer, Lippe, Goldtein, & Breitstone, LLP PHONE <br /> OWNER ADDRESS One Bridge Plaza,Suite 260 CITYISTATEIZIP Fort Lee/NJ/07024 <br /> CONTRACTOR Salem Engineering Group,Inc. PHONE 559-271-9700 <br /> CONTRACTOR ADDRESS 4729 W.Jacquelyn Avenue CITY/STATE/Zip Fresno/CA/93722 <br /> SUBCONTRACTOR Salem Engineering Group,Inc.DBA Salem Well Drilling PHONE 559-271-9700 <br /> SUBCONTRACTOR ADDRESS 4729 W.Jacquelyn Avenue CITY/STATE/ZIP Fresno/CA/93722 <br /> LICENSE C-57 C-61 D-09 .Other NUMBER 970772 EXPIRATION DATE 3/31/2020 <br /> Do TIC WELL SAMPLING General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE i I Domestic/Private 1 Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> 17 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well Replacement Well U Well Alteration/Modification Other <br /> D Monitoring Well(s) #of wells U Soil Bonng(s) a of borings Geotechnical 7 u of bonngs <br /> U Out-Of-Service Well C Out-Of-Service Well Renewal Cross-Connection Repair <br /> IJ New Pump U Pump Replacement ❑Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary D Air Rotary Auger Cable Tool Push Point Other <br /> Prosed Well Depth -> •3� ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> VX Casing Diameter_in Thickness/Gauge/ASTM Sched Steel U Plastic U Stainless Steel Other <br /> Grout Seal Depth Cr �� ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixR gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped [i Free Fall N Other Tremie Pipe I Retardant/Accelerator(name) <br /> PE TAL Installed By Driller is Pump Contractor Other <br /> I Concrete Pedestal❑Dimensions:VAdth ft Length ft Thick in Christy Box Stove Pipe <br /> ME 11 Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> I 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED I�hxh ke,"Ch TITLE Project Geotechnical Engineer DATE 3/19/2020 <br /> S IE E A T T A C H E D /�A <br /> S I T E IP L A N <br /> C O <br /> 6?0?0 <br /> f4VVc <br /> q 0NTY <br /> MFN' <br /> DEPARTMENT USE ONLY <br /> i <br /> Application Accepted By Date I OL Area ?rC L I Employee ID# L) r%1, <br /> Grout Inspection By. Date SPECIA Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Z Z'iL Constructed Well Depth ft <br /> COMMENTS s P r C r f? ' l� -J i• <br /> w:+tNr IsriPsH,+,r lik" h, hie <br /> PE SC Receivedeck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Reue t# <br /> d 1 Is /" <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />