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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 /> NON-REFUNDABLE PERMIT WWW.S OV.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> Joe ADDRESS Jce Pombo Parkway CIrY21P Tracy/95377 m <br /> D <br /> CROSS STREET W.Grant Line Road AP <br /> N 214-02040 _PARCEL SME 2.35 was LAND USE APPLICATION III O <br /> A <br /> OWNER NAME BSREP II WS Hotel Holding LLC ___ PHONE 980.368.8137 <br /> OWNER ADDRESS 10801 Monroe Road Suite B CITY/STATE/ZI► Matthews NC 28105 <br /> CONTRACTOR Terracon Consultants PHONE 925.609.7224 <br /> CONTRACTOR ADDRESS 902 Industrial Way CITY/STATEIZIP Lodi CA 95240 <br /> SUBCONTRACTORICONSULTANT California Geotech Services,LLC PNONE 831.634.1964 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 6886 Village Parkway CITY/STATE/LP Dublin CA94568 <br /> LICENSE X C-57 - C-61 -D-09 =Other NUMBER 812382 EXMRATION DATE 09/3012022 <br /> (BILLING PARTY: _OWNER XCONTRACTOR - SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING.-General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE -Domestic/Private =Irrigation/Agricultural - Industrial - Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Nemo Confect Nemo or Phone Number <br /> TYPE OF WORK =New Well - Replacement Well =Well Alteration/Modification -Other <br /> -Monitoring Well(s) #of wells -Soil Boring(s) #or borings X Geotechnical 2 #m bonngs <br /> =Out-Of-Service Well -Out-Of-Service Well Renewal =Cross-Connection Repair <br /> New Pum =Pump Replacement -Pump Repair =Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary -Air Rotary X Auger =Cable Tool = Push Point = Other <br /> Proposed Well Depth 20 ft Excavation 4- in diameter - Open Bottom - Gravel Pack)Gravel Sizein diameter <br /> - Conductor Casing in diameter I Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched - Steel - Plastic -Stainless Steel - Other <br /> Grout Seal Depth 20 if k Neal Cement(94 It,bag/5-10 gal water) - Sand Cement SaCk mur7 gal water <br /> -Bentonite(20%solids) = Other <br /> Grout Placement Method X Pumped - Free Fall =Other - Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other _ <br /> Concrete Pedestal Dimensions:Width It Length ft Thick In Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level R <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 /> MINIMU 48 OUR A CE N0110E REQUIRED FOR INSPECTIONS-PLEASE CALL(2U9)953-7697 <br /> SIGNED TITLE Principal DATE 7/27/2021 <br /> ,,,�� � f <br /> o ?p?� <br /> vH <br /> ym ...... � o " Fp FNT�gvNT r <br /> o o . - o ® �RTMFNT <br /> o 0 f 0 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By -f=—;22-Z— Date 17�f Area:.� G'7C _ Employee IDz _ <br /> s <br /> Grout Inspection By Date SPECIA Well Permit <br /> Pump Inspection By Dateof 'A WAIVER Received <br /> Soil Boring Inspection By� Date �O Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Reeehred Chel*N Amount Datepwmw Invoice# Well ID#I <br /> Codes Info Cash Remitted oe Re ue t <br /> 77v <br /> EHD t}0e 6111/2079 ���) /I �^ / ���� WELL rPUMP PERMIT <br />