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JOB ADDRESS i s, s- Sedan Avenue <br />Manteca Road 22610042 29.95 acres <br />CROSS STREET APN PARCEL SIZE LAND USE APPUCATION # <br />Megan Stover C/o Richmond American homes (for Owner) 707-689-7337 OWNER NAME PHONE <br />OWNER ADDRESS One Harbor Center, Suite 100 CM/STATE/ZIP Suisun City, CA 94585 <br />CONTRACTOR Hillside Drilling PHONE 209-815-5440 <br />. CONTRACTOR ADDRESS P O. Box 143 <br />SUBCONTRACTOR/CONSULTANT Mid Pacific Engineering, Inc. (MPE) PHONE 916-927-7000 <br />Cire/Zip Manteca, CA 95337 <br />CITY/STATE/ZIP Tracy, CA 95378 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 840 Embarcadero Drive, Suite 20 CITY/STATE/ZIP West Sacramento, CA 95605 <br />LICENSE X.C-57 C-61 D-09 Other <br />BILUNG PARTY: OWNER CONTRACTOR <br />NUMBER 800276 EXPIRATION DATE C/3o <br />SUBCONTRACTOR/CONSULTANT <br />Grout Placement Method Pumped Free Fall Retardant / Accelerator (name) Other <br />Steel Plastic Stainless Steel Other <br />ft Thick <br />PEDESTAL Other <br />ft Length Christy Box Stove Pipe <br />Installed By Driller Pump Contractor <br />Concrete Pedestal Dimensions: Width <br />Pump Set ft Standing Water Level ft PUMP HP Submersible Turbine Other <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 15 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched <br />Grout Seal Depth 15 ft )(Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixI7 gal water <br />Bentonite (20% solids) Other <br />in diameter <br />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 SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochicropropane (4392) Arsenic (4393) <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 :SS32100V 31IS New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells '.Soil Boring(s) 6 *of bonngs <br />Geotechnical <br />Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />TYPE OF WORK <br />Cot borings <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 />MINIMUM IjUR ADV NCE WTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE Owner Operator Hillside D !ling) DATE 06-09-2021 SIGNED <br />PAY <br />EC /0 <br />ON <br /> MENT <br />EIVED <br /> 0 9 2021 <br /> UIN COUNTY <br />ONMENTAL <br />DEPARTMENT <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By -•-/--. Date Q1/I 7 Area SirNil 11.'0 Employee ID# A 6...., <br /> <br />Grout Inspection By Date SPECIAL Well Permit <br /> <br />Pump Inspection By <br /> <br />Date WAIVER Received <br /> <br />Soil Boring Ir3pection By _V cd..tgrimaillsINIMIIIP/I, ••••• di - '- • Constructed Well Depith ft <br />COMMENTS VI )111 <br /> <br />pirt"- . . 1),E, / .f /(C'L'-1 W 4 •S e <br />s..) <br />f /7/31",„yrre .ro f-epe-K 1 re k 1 <br />rtmr 3o red.. <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />gash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />gra 1§0 <br />ifW <br />MA. 4:la IC tr1-71 m0042132- <br />SAN <br />EALni <br />NVIR <br />JOAO <br />6;4 4 EHD 43-06 6/11/2019 WELL /PUMP PERMIT