Laserfiche WebLink
Application Accepted By .-72 Dat ' 2/412 1 <br />DEPARTMENT USE ONLY <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By cl!taki :13144,4)•11\ENte 'L I k'c\ 1 -'' <br />COMMENTS <br />Codes <br />SC <br />Info <br />Received C.S21 Amount <br />Remitted Date Well ID//PE Permit/ <br />se ce eau eat it- Invoice # <br />"137 2 IS O ‘19---• D /1/ 160g 21-21 tArOggiveg <br />Area 3 ioo hf . Employee ID# 11.5 <br />0 SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth ft <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST H AZ ELTON AVENUE - STOCKTON CA 95205-6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRE 051 Spartan Way (see site plan) crrazip Lathrop / 95330 <br />CROSS STREET Land Park <br />OWNER NAME Saybrook CLSP, LLC <br />APN 19203035 PARCEL SIZE 20.6 LAND USE APPUCABON <br />PHONE 650-632-4522 <br />OWNER ADDRESS 303 Twin Dolphin Drive Crry/STATEMF Redwood Shores, CA 94065 <br />CONTRACTOR ENGEO / Victoria Drake PHONE 206-684-7615 <br />CONTRACTOR ADDRESS 17278 Golden Valley Pkwy. cnyisTATerzip Lathrop, CA 95330 <br />SUBCONTRACTOR/CONSULTANT GeoEx Subsurface Exploration PHONE 916-799-8198 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1510 Madera Drive cirrisTaferzip Dixon, CA 95620 <br />LICENSE J2C-67 0 C-61 0 D-09 0 Other NUMBER 654267 EXPIRATION DATE 7/31/2022 <br />BILLING PARTY: DOWNER 0 CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391)0 Dibromochloropropane (4392) o Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring if Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells 0 Soll Boring(s) ofbeings .12"GeotechnIcal 2 <br /> 4 of beings <br />TYPE OF WORK <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Alr Rotary 0 Auger 0 Cable Tool .12'' Push Point 0 Other <br />Proposed Well Depth 50 ft Excavation 2 In diameter 0 Open Bottom 0 Gravel Pack/Gravel Size In diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in ThicknessiGauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth 50 ft 2'N eat Cement (94/b bag15-10 gal water) 0 Sand Cement sack (MO gal water <br />0 Bentonke (20% solids) 0 Other <br />Grout Placement Method At Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />EI.M:_r#1- Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal °Dimensions: Width ft Length ft Thick In 0 Christy Box 0 Stove Plpe <br />PL11---AP 0 Submersible° Turbine 0 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 />MINI M 48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 'mix Project Engineer DATE 1/25/2021 <br />611 0.41 <br />I. <br />9,-1043-06 6/11/2013 WELL /PUMP PER/in