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Paradise Road <br />CITY/Zip Lathrop, CA 95330 <br />PARCEL SIZE*: .53 LAND USE APPLICATION # Stewart Road APN 21312006 <br />209-879-7900 <br />PHONE <br />Lathrop, CA 95330 <br />River Islands Development, LLC <br />73 Stewart Road CITY/STATE/ZIP <br />CONTRACTOR ADDRESS 1510 Madera Drive Dixon, CA 95620 CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT ENGEO Incorporated <br />SUBCONTRACTOR/CONSULTANT ADDRESS 17278 Golden Valley Parkway <br />PHONE 925-719-0822 <br />Cm6SrArErZip Lathrop, CA 95330 <br />L CONTRACTOR L SUBCONTRACTOR/CONSULTANT BILLING PARTY: L OWNER <br />LICENSE AC-57 C-61 L D-09 L Other NUMBER 954267 EXPIRATION DATE 07-30-2022 <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.S• • ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />Geo-Ex Subsurface Exploration PHONE 916-799-8198 <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />,SEE ATTACHED <br />DEPARTMENT USE N L Y <br />DOMESTIC WELL SAMPLING: E General Mineral/Coliform Bacteria (4391) E Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE L Domestic/Private L Irrigation/Agricultural L Industrial L Water Quality Monitoring L Soil Sampling/Characterization <br />L Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />L Well Alteration/Modification L Other <br />L Monitoring Well(s) # of wells L Soil Boring(s) fl of borings LXGBOteChniCal <br /> of borings <br />TYPE OF WORK L New Well L Replacement Well <br />L Out-Of-Service Well <br />L Out-Of-Service Well Renewal L Cross-Connection Repair <br />L New PUMD L Pumn Reolacement I Pumn Ranair I Raise Well Caninn <br />WELL CONSTRUCTION <br />Drilling Method L Mud Rotary Air Rotary L Auger L Cable Tool L Push Point ix Other Cone Penetration Test <br />Proposed Well Depth 'P Excavation 2 in diameter L Open Bottom L Gravel Pack/Gravel Size in diameter <br />, Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter inThickness/Gauge/ASTM Sched L Steel L Plastic L Stainless Steel L Other <br />Grout Seal Depth TeleOlkItt LXNeat Cement (94/b bag/5-10 gal water) L Sand Cement sack mix/7 gal water <br />. Bentonite (20% solids) L Other <br />Grout Placement Method L Pumped L Free Fall L r L Retardant / Accelerator (name) <br />PEDESTAL Installed By L Driller L Pump Contractor L Other <br />L Concrete Pedestal Dimensions: Width ft Length ft Thick in L Christy Box L Stove Pipe <br />L SubmersibleL Turbine L Other <br /> <br />Pump Set ft Standing Water Level PUMP HP 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED Jason Sedore TITLE DATE Staff Geologist 6/25/2021 <br />*Am- <br />t <br />6 <br />qil <br />116,4 <br />CEIv <br />PAY/14ENo <br /> <br />.7. <br />RE <br /> jtitt-0 2021 <br />gvivcritRA8,471fity- co o <br />ENT41:17. Itli PARTm ENT <br />Application Accepted By ,or Date Area Sig Employee ID# A s <br />Grout Inspection By 7 SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />ft Soil Boring Inspledon By _w <br />COMMENTS <br />Date Constructed Well Depth <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By„., <br />Chec Amount <br />Remitted iDate Permit/ <br />Service Request # Invoice # Well ID# <br />1437; )60 dIV - 1_ g6, *(15.-- /114CY( liAWOOLI 272- I <br />END 43-06 6/11/2019 <br />WELL /PUMP PERMIT