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DEPARTMENT USE ONLY <br /> Date tilOP Employee ID# <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE *SToctcroN CA 95205 -6232 (209)468-3420 <br />NON-P"UNDABLE PERMIT www.s • ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDIK5ri Spartan Way (see site plan) crryizip Lathrop / 95330 <br />CROSS STREET Land Park APN 19203034 <br />PARCEL SIZE 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 <br /> ENGEO / Victoria Drake PHONE 209-684-7615 <br />CONTRACTOR ADDRESS 17278 Golden Valley Pkwy. crryisTATErzip Lathrop, CA 95330 <br />SUBCONTRACTOR/CONSULTANT GeoEx Subsurface Exploration <br />PHONE 916-799-8198 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1510 Madera Drive <br />crryisrATEizip Dixon. CA 95620 <br />LICENSE WC-57 0 C-61 0 D-09 0 Other NUMBER 954267 EXPIRATION DATE 7/31/2022 <br />BILLING PARTY: 0 OWNER <br /> 0 CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <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 ft Soil Sampling/Characterization <br />0 Public Water System <br />If afferent from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well <br />0 Monitoring Well(s) #01 wells <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal <br />0 New Pump 0 Pump Replacement 0 Pump Repair <br />0 Cross-Connection Repair <br />0 Raise Well Casing <br />0 Well Aiteration/Moditication 0 Other <br />0 Soil Boring(s) # of borings .121" GeotechnIcal 1 of baings <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Alr Rotary 0 Auger 0 Cable Tool ..gr' 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 2N eat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix17 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other _ 0 Retardant / Accelerator (name) <br />PEDESTAL installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal ODImenslons: Width ft Length ft Thick In 0 Christy Box 0 Stove Pipe <br />PUMP <br /> 0 Submersible 0 Turbine 0 Other HP <br />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 15 <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 riTLE Project Engineer DATE 1/25/2021 <br />Application Accepted By <br />Grout Inspection By <br />Pump inspection By <br />Soil Boring Inspection ByaillVlif" <br />COMMENTS ic • <br />Date 0 SPECIAL Well Permit <br />Date 0 WAIVER Received <br />Date 1.--\ kc\ k 7--\ Constructed Well Depth <br /> <br />ft <br />PE <br />Codes <br />SC <br />info <br />Received <br />Am" <br />Qlesieckffvfri,,? Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />43742 PrO ‘4V-"' q2/12*-- 'NA WfW41699g 911gt14 <br />EHD 43-06 8/11/2019 WELL /PUMP PERMIT