Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - SrocicroN CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB R f ADDICIE ° I Spartan Way (see site plan) <br />CROSS STREET Land Park APN 19203033 <br />PARCEL SIZE 19.5 LAND USE APPUCATION # <br />OWNER NAME <br /> Saybrook CLSP, LLC <br />PHONE 650-632-4522 <br />OWNER ADDRESS 303 Twin Dolphin Drive <br />CITY/STATE/ZIP Redwood Shores, CA 94065 <br />CONTRACTOR ENGEO / Victoria Drake PHONE 209-684-7615 <br />CONTRACTOR ADDRESS 17278 Golden Valley Pkwy. crryisTATErzip Lathrop, CA 95330 <br />CITY/ZIP Lathrop / 95330 <br />SUBCONTRACTOR/CONSULTANT GeoEx Subsurface Exploration PHONE 916-799-8198 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1510 Madera Drive <br />CITY/STATE/ZIP Dixon CA 95620 <br />LICENSE ,XC-57 0 C-61 0 D-09 0 Other NUMBER 064267 EXPIRATION DATE 7/31/2022 <br />BILLING PARTY: 0 OWNER 0 CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />PUMP HP Pump Set ft Standing Water Level ft 0 Submersible 0 Turbine 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />ft Thick <br />PEDESTAL O Other <br />ft Length In 0 Christy Box 0 Stove Pipe <br />Installed By 0 Driller 0 Pump Contractor <br />0 Concrete Pedestal ODimensions: Width <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool ?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 /> <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth 50 ft Jr Neat Cement (94 lb bagI5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) 0 Other <br />• <br />WELL/PUMP PERMIT <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 7 Soil Sampling/Characterization <br />0 Public Water System <br />If dIffen3nt from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well AlteratIon/ModificatIon 0 Other <br />0 Monitoring Well(s) <br /># of wells <br />0 Out-Of-Service Well <br />o New Pump 0 Pump Replacement <br />0 Soil Boring (s) * of borings ZGeotechnical 1 it of bonngs <br />0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 Pump Repair 0 Raise Well Casing <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 TITLE Project Engineer DATE 1/25/2021 <br />tialoh Lagi <br />DEPARTMENT U E NLY <br /> <br />Application Accepted By --,4.3/..___ Date -2 4' '2 1 Area 1/1-4, Atop Employee ID# A 5 <br /> <br />Grout Inspection By Date 0 SPECIAL Well Permit <br /> <br />Pump Inspection By Date 0 WAIVER Received <br />Soil Boring Inspection By(10Ety".. Date "I 1 V2k k -LA Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Ely, <br />ChLerjpc <br />s <br />Amount <br />Remitted Date Permit/ <br />aervice Request # , Invoice # Well !IV <br />437) Iej *--4, D__113 *qs-c. 1 -111 r wootnoil <br />E140 43-06 6/11/2019 <br />WELL /PUMP PERM fT