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WELL/PUMP PERMIT CIO <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOB ADDRESS 12030 S Harlan Rd CrrY/ZIP Lathrop, 95330 <br />CROSS STREET N/A R 3 ii ; APN 196-030-280-000 PARCEL SIZE 32.6 ac LAND USE APPLICATION # <br />OWNER NAME BMG2 Fntar rin CPC I P PHONE <br />OWNER ADDRESS 3736 Fallon Road #410 CRY/STATEIZIP Duhlin CA 94568 <br />CONTRACTOR Cornerstone Earth ro ID PHONE _(408) 245-4600 <br />CONTRACTOR ADDRESS 1259 Oakmead Parkway CRY/STATE/ZIP Sunnyvale, CA 94085 <br />SUBCONTRACTOR/CONSULTANT_M*dcilp Faith Geotestinq, Inc. PHONE (714) 633-5025 <br />SUBCONTRACTOR/CONSULTANTADORESS 27639 Industrial Blvd CITY/STATEIzIP Hayward, CA 94[/545 <br />LICENSE X C-57 Cbl D-09 Other NUMBER 8994.51 ExPIRATION DATE K' <br />BILLING PARTY: OWNER XCONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestir/Pdvate Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />1 rre OF WORK New wen Replacement Well Well Alteralion/Modification Other <br />Monitoring Wells) # of wells XSoil Boring(s) -5 _ x or borings Geotechnical x or bonngs <br />Out-OfService Well Out -Of -Service Well Renewal Cross -Connection Repair <br />:i New Pump 7 Pump Replacement Pump Repair Raise Well Casino <br />Drilling Method Mud Rotary f Air Rotary Auger Cable Tool Push Point X Other CPT Cone <br />Proposed Well Depth 50-100 ft Excavation 1.4 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad . Steel Plastic Stainless Steel Other <br />Grout Seal Depth ;> 7 - } ft X Neat Cement (94 /b bag15-10 gal wafer) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) X Other Borings backfilled with grout per county guidelines <br />Grout Placement Method Pumped A Free Fall X Other -Ar Tremie 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 />PUMP Submersible Turbine Other HP 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 IS <br />CURRENT AND ACME WITH THE CALikbRNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS CO EN ION LAWS. <br />MIN141Ur' -S R N OTICE REQUIRED FORI,N1r1SPECTIONS - PL ASE CALL (209) 95`3-)7697 <br />SIGNED TITLE �U nIYi. h�r'1 Tr /0-y \ DATE -(//Zo M <br />DEPARTMENT URE ONLY <br />Application Accepted By ��'"/�,... Dale —/,x 11 <br />Grout Inspection By %U. 1 L Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Lam' till: " 9 Employee ID# I rk <br />IJ SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth H <br />N <br />0 <br />A <br />N <br />�J QED <br />IVAY 2 <br />IRONM COUNT <br />Ty OEPARTM L <br />EHD 43-06 6111,2019 (*i1 <br />12-'s <br />'�3 / WELL /PUMP PERMIT <br />