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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1400 E Pescadero Ave Tracy,95304 m <br /> JOB ADDRESS CITYIZIP D <br /> CROSS STREET N MacArthur Dr APN 213-07-ftO Qp /p PARCEL SIZE 18.46 ac LAND USE APPLICATION# <br /> OWNER NAME IPT Tracy DCV,LLC PHONE va <br /> OWNER ADDRESS 518 7th St,7th Floor CITY/STATE/ZIP Denver,CO 80202 <br /> CONTRACTOR Cornerstone Earth Group PHONE (408)470-0725 <br /> CONTRACTOR ADDRESS 1259 Oakmead Parkway CrrY/STATE/ZIP Sunnyvale,CA,94085 <br /> SUBCONTRACTOR Cuesta Geo PHONE (925)872-1248 <br /> SUBCONTRACTOR ADDRESS 2709 Kapalua Court CIry/STATE/ZIP Fairfield,CA,94534 <br /> LICENSE XC-57 C-61 D-09 i;Other NUMBER 1043431 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X 37.760035 y -121.408838 Township_ Range Section_ <br /> INTENDED USE Domestic/Private Irrlgadon/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. water byStern Name one ame or one um er <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells X Soil Bor ng(s) #of borings X Geotechnical 13 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 5 t0 25 It Excavation 6 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 Sched Steel Plastic 1.Stainless Steel Other <br /> Grout Seal Depth $ N 2Y It X Neat Cement(94/b bao-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) X Other Backfilling Der county requirements <br /> Grout Placement Method X Pumped i;Free Fall j Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level it <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 24 HOUR ADYANCE N�T�CEk� EQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> gna lysigned y hris reg <br /> SIGNED ON:cn=Chris Krieg,o=CG,ou, TITLE President DATE 4/13/20 <br /> oma=rle c rs@s c o a.net, <br /> c= S---- <br /> X ULIMC <br /> 'Me IV <br /> Ep <br /> ? 1020 <br /> A <br /> L ' ENT,4 NTy <br /> ARTMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � Date y 0? ZQZO Area S1fteJCV Employee ID# DA <br /> Grout Inspection By Date (l SPECT L Well Permit <br /> Pump Inspection By Dale WAIVER Received <br /> Soil Boring Inspection By Date Y w`12©Z6 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received &heqW Amount Date Permit/ <br /> Codes Well ID# <br /> Codes Info B s Remitted Service Request# <br /> Y37a Iso Szl $,2a Ro +1110 V�PO <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30112 <br />