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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE • STOCKTON CA 95205 -6232 (209) 468 -3420 <br />.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOE ADDRESS 1010 Industrial Drive crTyrap Stockton. CA 95206 <br />CROSS STREET S Airport Way ApN 177-280-130 PARCEL SIZE 9.6 ac LAND USE APPLICATION $ <br />D <br />i <br />OWNER NAME Ingredion, Inc. RHONE <br />en en <br />OWNER ADDRESS 1021 Industrial Drive crryisTATEau, Stockton, CA 95206 <br />CONTRACTOR Middle Earth Geotesting, Inc PHONE (714) 633-5025 <br />CoNTRAcToR ADDRESS 27639 Industrial Boulevard cawsrArEale Hayward, CA 94545 <br />SuBcoNTRAcToR/CoNsuLTANT Cornerstone Earth Group PHONE (408) 245-4600 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1259 Oakmead Parkway CrrviSTATEflin Sunnyvale, CA 95050 <br />X C-57 C-61 0-09 Other NUMBER 899451 ExpiRATION DATE LICENSE <br />BILLING PARTY! OWNER CONTRACTOR )(SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic./Private Imgation/Aghcultural Industrial Water Quality Monitonng Soil Sampling/Characterization <br />Public Wailer System <br />it MIlomnIlmen OW,/ W AIM Syslom are CaMact Nam,, or Prom, N,/mbor <br />TYPE OF WORK New Well Replacement Well Well Alteration:Modification Other <br />XGeolechnical 2 ..i.,,,,, Monitoring Well(s) dot wells XSoil Boring(s) II 01 bormus <br />Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point X Other Cone Penetration Testing <br />Depth 150 It Excavation 2.5 in diameter Open Bottom Gravel Pack/Gravel Size in diameter Proposed Well <br />Conductor Casing in diameter 1 Conductor Casing Depth ri <br />Casing Diameter in Thickness/Gauge/ASTM Sched Sleet Plastic Stainless Steel Other Well <br />Grout Seal Depth ' i ft r 'Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water . . <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Ar Other ''' r • Retardant' Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />Submersible Turbine Other HP Pump Set ft Standing Water Level It Pump <br />I HEREBY CE: T <br />JOAQUIN C • NTY OR .INANCES, <br />CURREN ND ACTIVE <br />WORKERS MPENSA <br />MI 14.4:N,..48 <br />\'..... <br />T I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL <br />STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY <br />WITH THE 44ORNlA CONTRACTORS STATE LICENSE BOARD AND <br />ON LAWS. .. <br />kr - •V. 47..E ."- CE REQUIRED RDA% )NSPECTONS,- PL <br />TITLE 4 rienAilt(414.41-efl <br />fk <br />itilaylATE <br />BE DONE IN ACCORDANCE WITH SAN <br />THAT MY REQUIRED LICENSE IS <br />THAT I AM IN COMPLIANCE WITH ALL <br />SE CALL (209) 953-7697 <br />2-12 S /7 02-g SIGNED <br />F' <br />11111111111 1111111. 111111' 111111111 lIII 111111111111I 1111l <br />c <br />- 3 <br />ymr. cN T <br />L-t) <br />1 <br />2021 <br />LPN cou NmEN , N <br />EPA '4 7-1 N 7_ <br />DEPARTMENT USE ONLY <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inection By <br />COMMENTS ,P4zony417042- ki • (.•:..ilckid <br />Date WAIVER Received <br />Dale 7-ili W7- Constructed Well Aspth <br />Al- )1'4 erso r, ft <br /> <br />PE <br />Codes <br />SC <br />Into <br />Received Checktli <br />,Cash <br />Amount <br />Remitted <br />Date , <br />Permit/ <br />rviie It _Re9uest <br />IA! cul-r -vi__ <br />Invoice 0 Well IN <br />1 5-b <br />41(k,) <br />V j-`-it_- 1 .:-.,- ' ¶1 (21 <br />- A <br />/72-- 4-‘" _ Application Accepted By Area - Employee ID# Date <br />• - <br />/.24.300 WELL .PINP E • <br />£10 43.06 6/11/2019