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' r WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE www.sjgov.org/ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />PERMIT <br />JOB ADDRESS CO i / Sc h1)ipe- <br />CITY/ZIP Tracy, CA 95377 <br />CROSS STREET Hansen Road APN 209-120-09 <br />PARCELSIZE 379 Ac LAND USE APPLICATION# <br />Prologis <br />OWNER NAME ILP <br />PHONE <br />3353 Gateway Blvd. ,-. )��� <br />Fremont, CA 94538 pe on <br />OWNER ADDRESS / <br />CnY/STATE2IP 1 <br />CONTRACTOR ENGEO <br />PHONE 209-835-0610 <br />CONTRACTOR ADDRESS 17278 Golden Valley Pkwy. <br />CITY/STATE/ZIP Lathrop, CA 95330 <br />West Coast Exploration <br />209-985-7541 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS P.O. Box 133 <br />CnY/STATEMP Escalon, CA 95320 <br />870761 01/31/2022 <br />LICENSE `. C-57 C-61 D-09 Other <br />NUMBER EXPIRATION DATE <br />BILLING PARTY: OWNER xCONTRACTOR <br />SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private 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 />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings x Geotechnical 4 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />"u - <br />nurse Well <br />Drilling Method Mud Rotary Air Rotary x Auger Cable Tool Push Point Other <br />Proposed Well Depth 25 ft Excavation 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/GaugelASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth957 ft x Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped x Free Fall Other Retardant I 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />AMINIMUM $giHOLM ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />iT�;i'• <br />SIGNED". "! y;!s _/7(�1,/'•,�� E TITLE Project Engineer DATE 08/1672021 <br />N <br />g <br />O <br />) boaoa <br />18 2021 <br />JMEN��NTy <br />PAR rMENT <br />J DEPARTMENT USE (ONLY <br />Application Accepted By �!� Date CIXI; 6 Area S -rr4G Employee ID# <br />Grout Inspection By 10 Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boning ,Inn ection By Date _ Date Construct d Well De th ft <br />COMMENTS 1 ffrAV II � P;ID( t/5� l tr C:YOU ! l^�C E:f 15 t /�C'DI) ' P, ) v,I' bD7llt!/ tc drez <br />EHD 43-06 6/11/2019 (�W-' :�P /3 d / 93 0 39 WELL /PUMP PERMIT <br />am, <br />fMVIUJ <br />IMUM H1tf01UJI70 03'2=ilT <br />EHD 43-06 6/11/2019 (�W-' :�P /3 d / 93 0 39 WELL /PUMP PERMIT <br />