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` WELL/PUMP PERMIT <br />r SAN JOAWIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209) 4683420 <br />N-KEFUNDABLE PERMIT - wNMr-SJgoy.org/eno tA19Ktb 7 TEAR FROM DATE ISSUED <br />ADDRESS 1850'W of intersection of Stewart Rd & W Stewart Rd (37 788073., -121 316502) CITY/ZIP Lathrop, CA / 95330 <br />SS STREET W Stewart Rd 7uc. " APN 210-21-001 PARCEL SIZE 92 acre LAND USE APPLICATION #' <br />IER NAME Califia, LLC PHONE (209) 879-7900 <br />IER ADDRESS 73 Stewart Rd CITYISTATEIZIP Lathrop, CA 95330 <br />CTOR Andrew Hernandez, West Coast Exploration, Inc. <br />CTOR ADDRESS PO Box 133 <br />TRACTOR/CONSULTANT Consultant: Exponent, Inc. <br />TRACTORICONSULTANT ADDRESS 475 14th SL, Suite 400 <br />id C-57 ❑ C-61 ❑ D-09 ❑ Other <br />PARTY: L OWNER 0 CONTRACTOR <br />PHONE (209)985-7541 <br />CITYISTATEIZIP Escalon, CA 95320 <br />PHONE (510) 387-2386 <br />CITYISTATEIZIP Oakland, CA, 94612 <br />NUMBER EXPIRATION DATE <br />'? SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: O General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) U Arsenic (4393) <br />NTENDED USE ❑ DomesbclPrivate ❑ Irrigation/Agncultural 0 Industrial ❑ Water Quality Monitoring Y Soil Sampling/Characterization <br />CI Public Water System <br />If different from Omer: Water System Name Contact Name or Phase Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Weli(s) # of wells ❑ Soil Bonng(s) #of borings 1 Geotechnical 0 o Daings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal L7 Cross -Connection Repair <br />❑ New Pump ❑ PumD Replacement ❑ Pump Repair ❑ Raise Well Casino <br />PAYjot�,,,. <br />Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tooi ❑ Push Point ❑ Other <br />(Drilling <br />Proposed Well Depth <°,27' _ft Excavation in diameter E Open Bottom F., Gravel Pack(Gravel Size in diameter <br />vV le 0) <br />V <br />D Conductor Casing in diameter I Conductor Casing Depth ft <br />CJ <br />Well Casing Diameter3-) in Thickness/Gauge/ASTM Sched ;i Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />U</ <br />Grout Seal Depth ft t3'Neat Cement (94 /b bag/5-10 gal water) ❑ Iment sack mix17 g Aj�r <br />rl <br />+i Bentonite (20% solids) ❑ Other f O i <br />gQi/l/yC <br />O(��) <br />Grout Placement Method ❑ Pumped Free Fall ❑ Other I; eterdant / r (name) <br />" <br />O/yMF Y, <br />PEDESTAL Installed By ❑ Driller C Pump Contractor '. Other <br />DEPgR�rgC <br />A'EN7 <br />Concrete Pedestal ❑Dimensions Width ft Length ft Thick in ❑ Christy Box Stove Pipe <br />MP ❑ Submersible-- Turbine 11 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 />,' vriv HOU//b` ADV NCE NOTICE REQUIRED FOR INSPECTIOrN�S -- PLEASE CALL (209) 953-7697 <br />SIGNED TITLE PyesC d- / r'f' DATE 3- «'V <br />/ <br />DEPARTMENT USE ONLY <br />Application Accepted By "�- � �— Date 3 yS Area S ZC, t k C' Employee I D# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date L7 WAIVER Received <br />Soil Boring Impaction� Date Constructed Well Depth R <br />COMMENTS �t?lrY►�le- 1D;ipr -jo Lv vSP it; crOL;1[' J�; Pr rc <br />EHD43-06 6/112019 WELL/PUMP PERMIT <br />