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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE neouiT WWW.S. ov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Joe Pombo Parkway CITY/Zlp Tracy 195377 m <br /> CROSS STREET W.Grant Line Road APN 214-02040 pAltCF1SIZE 2.35 eaes LAND USE APPLICATION# g <br /> OWNER NAME BSREP II WS Hotel Holding,LLC PHONE 980.368.8137 <br /> OWNER ADDRESS 10801 Monroe Road Suite B CnY/STATB/ZW Matthews NC 28105 <br /> CONTRACTOR Terracon Consultants pHon 925.609.7224 <br /> CONTRACTOR ADDRESS 902 Industrial Way CITYISTATE17JP Lodi CA 95240 <br /> SUBCONTRACTOR/CONSULTANT Middle Earth Geotesting PHONE 831.634.1964 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 954 N Lemon Street CrTY/STATE/ZIP Orange CA 92867 <br /> LICENSE X C-57 C-61 -D-09 -Other NUMBER 899451 ExpIRATION DATE 06/30/2023 <br /> BILLING PARTY: -OWNER XCONT1tACTOR - SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:-General MineraUColiform Bacteria(4391)-Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE -Domestic/Private -Irdgatior✓Agricultural - Industrial -Water Quality Monitoring )C Soil Sampling/Characterization <br /> -Public Water System <br /> N ddrenml from Owner Water system Nome, Contact Name or Phone Number <br /> TYPE OF WORK =New Well -Replacement Well -Well Alteration/Modificallon =. Other <br /> -Monitoring Wells) N of wells -Soil Boring(s) a of borings X Geotechnical 2 CPTs eel boimSe <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 Test <br /> Proposed Well Depth 100 ft Excavation 1 3/4' 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 100 ft X Neat Cement(94 lb baW5-10 gal water) -Sand Cement saci,mix/7 gal water <br /> -Bentonite(20%solids) -Other <br /> Grout Placement Method -Pumped �X Free Fell =Other -Retardant/Accelerator(name) <br /> Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width 1t Length ft Thick In _ Christy Box _.:Stow 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM M 8 HOUR ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Principal DATE 7/27/2021 <br /> I�• I - <br /> ". ... O <br /> i <br /> 4'm O O <br /> C' <br /> O <br /> M tvtw1% <br /> M <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � �L Date &I Area = «OG Employee ID#AS <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By 4 Ok Date WAIVER Received <br /> Soil Boring Inspection By Date0�-� Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received C-ch-mo Amount Da Permw Invoice A Wen IDI/ <br /> Codes Into Remitted Sella St it <br /> a o $609 IMP m26097WL4 <br /> EHD a3-d6 1111112019 r-LLT �(J��`"--� <br />