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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 />NUN-KEFUNDABLE PERMIT www.sjgov.org/ehd <br />EXPIRES 1 YEAR FROM DATE ISSUEC <br />F Mr. Mi lllin RnArl <br />Manteca 95337 <br />JoBADDREss 3�J(:' <br />CITY/ZIP <br />6. maYs Rd. 241350,310 s'S nc n/a <br />CROSS STREET APN <br />PARCEL SIZE LAND USE APPUCATION # <br />OWNER NAME SolAgra Corp... ',r I'6. -LLC <br />PHONE 415-898-3823 <br />OWNER ADDRESS 1100 Cabro Ridge <br />CITY/STATE/Z1P Novato, CA, 94947 <br />Geo -Ex <br />916-799-8198 <br />'i CONTRACTOR <br />PHONE <br />1510 Madera Dr. <br />Dixon, CA, 95620 <br />CONTRACTOR ADDRESS <br />CITYISTATEihP <br />SUBCONTRACTORICONSULTANT Engeo <br />PHONE 209-835-0610 <br />17278 Golden Valley <br />Pkwy/�CI7Y/STATEZ <br />Lathrop, CA, 9533,( <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />P <br />LICENSE x C-57 C-61 D-09 Other <br />NUMBER J 1 2 ('n <br />, ExPIRAON DATE iL') ✓` <br />Q <br />BILLING PARTY: OWNER CONTRACTOR <br />X SUBCONTRACTOR/CONSULTAM <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bactena (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domesfic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />II deerent from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well AAerationlModification XOther CPT/ soli Boring <br />Monitoring Well(s) # of wells X Soil Bonng(s) a of borings X Geotechnical 2 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method XMud Rotary ❑ Air Rotary Auger Cable Tool Push Point X Other CPT <br />Proposed Well Depth 100 ft Excavation 2 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 Silted Steel Plastic ! Stainless Steel Other <br />Grout Seal Depth It X Neat Cement (94 ;b bag/5-10 gal water) Sand Cement sack mrxA gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall XOther Tremi a Retardant /Accelerator (name) <br />PEDESTAL installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width R Length ft Thick in - Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set R 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. 1 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 />",11NIh14J �0UR �D� NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED / i�/Z- TITLE Engineer DATE 5-21-21 <br />N <br />w <br />DEPARTMENTSE ONLY <br />Application Accepted By 'L1' Date �% Area � � Employee ID# <br />Grout Inspection By — Date Z7Tj SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE Sc Received Check*/ Amount Date Permit/ Invoice # Well ID# <br />Codes Into Caash. � Remitted •rvice Re uest# <br />•r _..t L-.C� �SJ <br />EHCe3-05 61112019 WELL( PUMP PERMIT <br />aX/ 1 ��'3.3 �R3 <br />�VNr <br />Fo <br />?021 <br />N° / <br />rMeN r <br />