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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468.3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> V1 <br /> JOB ADDRESS 20250 N.Staten Island Road CITY/ZIP Thorton.Califomia m <br /> D <br /> CROSS STREET Staten Island APN 069.02-019 PARCEL SIZE 9052 LAND USE APPLICATION# p <br /> m <br /> OWNER NAME Nature Conservancy PHONE N <br /> OWNER ADDRESS 201 Mission Street.41h Floor CITY/STATEIZIP San Francisco.California 94105 <br /> CONTRACTOR Cascade Drilling PHONE 916-638-1169 <br /> CONTRACTOR ADDRESS 3000 Duluth Street CITY/STATi West Sacramento,California 95961 <br /> SUBCONTRACTOR/CONSULTANT Hultgren-Tlllis Engineers PHONE 925-685-6300 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4085 Nelson Avenue,Suite A CITY/STATE/ZIP Concord,California 94520 <br /> LICENSE + C-57 C-61 .. D-09 D Other NUMBER 1058336 EXPIRATION DATE 0913012021 <br /> BILLING PARTY: OWNER C CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quakily Monitoring i Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK -New Well 7 Replacement Well C Well AlterationlModiffcation - Other <br /> Monitoring Well(s) #of wells ❑Soil Boring(s) o of bodng6 V Geotechnical 2 #of borings <br /> Out-Of-Service Well G Out-Of-Service Well Renewal Goss-Connection Repair <br /> New Pum :i Pump Replacement _Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary v Auger Cable Tool —_Push Point Other <br /> Proposed Well Depth 30 it Excavation in diameter =Open Bottom Gravel Pack/Gravel Size in diameter <br /> - Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 30 ft +. Neal Cement(94/b bag/5-10 gat water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) _:Other <br /> Grout Placement Method ED Pumped - Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller - Pump Contractor - Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick In Christy Box Stove Pipe <br /> PUMP - 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 /> Mg1.tL IUM 48 O�U/rF2 ADVANCE NOTICE REQUIRED FOR SPECT -PLEASE CALL(209)953-7697 <br /> SIGNED L�C.GF/ W� TITLE rojec Manager DATE 1/27/21 <br /> See Attached <br /> cF��Nr <br /> E� <br /> ®2 z0?1 <br /> DEPARTMENT USE ONLY f� ryDFMFNT4 7)- <br /> Application Accepted By 1 J [�L_ Date d Area 1 �/ Employee ID# <br /> + T <br /> Grout Inspection By Date L L L 1 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received AmountD to PermiU Invoice# Well ID# <br /> Codes Info B Remitted Service Re ueSt# <br /> z ' 1 � <br /> EHD43-06 &112019 WELL+PUMP PERMIT <br />