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JOB ADDRESS 29592 South Corral Hollow Road <br />CROSS STREET W Linne Road Ap(253-020-13170, 180, and -190 <br />OWNER NAME RIDGELINE PROPERTY GROUP, LLC <br />crrazip Tracy, California <br />PARCEL SIZE 194 LAND USE APPLICATION # <br />PHONE 916-284-3245 <br />OWNER ADDRESS 915 HIGHLAND POINTE DRIVE, SUITE 250 <br />CONTRACTOR Taber Drilling <br />CONTRACTOR ADDRESS 536 Galveston St <br />SUBCONTRACTOR/CONSULTANT Wallace-Kuhl & Associates <br />SUBCONTRACTOR/CONSULTANT ADDRESS 3050 Industrial Blvd <br />CITY/STATE/ZIP ROSEVILLE, CA 95678 <br />PHONE (916) 371-8234 <br />CITY/STATE/ZIP West Sacramento, CA 95691 <br />PHONE 916'997'1546 <br />ardsTATEmp West Sacramento, CA 95691 <br />LICENSE 1Yr C-57 I C-61 ' D-09 H Other NUMBER 969927 EXPIRATION DATE 2/28/2022 <br />BILLING PARTY: OWNER <br /> <br />CONTRACTOR IV SUBCONTRACTOR/CONSULTANT <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />Grout Placement Method Pumped V Free Fall Other Free fall or Trenae Pipe Retardant / Accelerator (name) <br />ft Thick <br />PEDESTAL <br />in Christy Box Stove Pipe <br />Installed By 11 Driller I Pump Contractor I Other <br />Concrete Pedestal Dimensions: Width ft Length <br />PUMP HP Pump Set ft Standing Water Level ft Submersible Turbine Other <br />C2_ <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 />IMUM 48 H015ADVANCE NOTICE REQUIRED FOR I SPEC NS - P EASE CALL (209) 953-7697 <br /> DATE ''.2411Q SIGNED TITLE <br />ft <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary V Auger Cable Tool Push Point Other <br /> <br />Proposed Well Depth 20 ft Excavation in diameter I. Open Bottom j Gravel Pack/Gravel Size <br /> <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel j Plastic 1. Stainless Steel I Other <br /> <br />Grout Seal Depth ft V Neat Cement (94 lb bag/5-10 gal water) Sand Cement <br />[ Bentonite (20% solids) 1 Other <br />sack mix/7 gal water <br />in diameter <br />tor 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 />DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) I Arsenic (4393) <br />TYPE OF WORK New Well Replacement Well I Well Alteration/Modification I Other <br /> <br />Monitoring Well(s) # of wells Soil Boring(s) #01 borings V Geotechnical 5 #01 borings <br />. Out-Of-Service Well [ Out-Of-Service Well Renewal i i Cross-Connection Repair <br />New Pump Pump Replacement Pump Repair I Raise Well Casing <br />DEPA TMENT US,E ONLY <br />Application Accepted By I.• <br />4 -frac y „ <br />../ .. 1- .or A .. Date / I Area Employee ID#_1:>et <br />Grout Inspection By Ilito'VEALVIW Date '2.- 2_ I , SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Cils.....4car Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />ct3V / 5:20 (02-- 1 0 c 9- i•Iii-7-1 r6 11\1;6 :SS3NCICIV 311S ft <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT