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L <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1968 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT WWW.5Jg0V <br />Jos ADDRESS 697 N. Airport Way <br />CROSS STREET W Louise Ave APN 19816029 <br />OWNER NAME Paul Lopez C/o Richmond American Homes (for Owner) <br />OWNER ADDRESS One Harbor Center, Suite 100 <br />CONTRACTOR Taber Drilling <br />CONTRACTOR ADDRESS 536 Galveston St. <br />SUBCONTRACTOR/CONSULTANT Mid Pacific Engineering, Inc. (MPE) <br />840 Embarcadero Drive Suite 20 <br />tAYIKtJ T TEAR FROM DATE 155ULU <br />CITY/Zlp Manteca, CA 95337 <br />106.01 acres <br />:CEL SIZE LAND USE APPLICATION # <br />PHONE 925-413-1163 <br />CITY/STATE21P Suisun, CA 94585 <br />PHONE 916-371-8234 <br />CITY/STATE/ZIP West Sacramento, CA 95691 <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/Zip- <br />LICENSE x C-57 C-61 D-09 Other NUMBER 969927 <br />BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br />PHONE 916-927-7000 <br />West Sacramento, CA 95605 <br />EXPIRATION DATE 02.28.2022 <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 />r— n. w— M. -1A1.11 Rcnlaro nt UV.11 Wall Allaralinn/Mndifirafinn X nth., 8 CPTs <br />Monitoring Wells) # of wells Soil Boring(s) # of bonngs Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool X Push Point Other <br />Proposed Well Depth 50 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth fl <br />Well Casing Diameter 4 in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 50 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 / 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 It <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 />299�rUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Executive Vice President DATE 09-23-2021 <br />DEPARTMENT USE ONLY y p/�� <br />Application Accepted By � Date oT Area / ; ✓f+�<<r'Employee ID# A L <br />Grout Inspection By 'r'itllt:yflL �13+,/1�A .OAu2. Date- �� SPECIAL W211 Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS <br />VI <br />in <br />D <br />A <br />In <br />N <br />EHD43-06 6/112019 CCA <br />W : 13 <br />2— 1 C�_) 8 1�i WCL[./r',,Mi'PCRMI' <br />@M <br />UFWAlltL7IT' <br />1 �i6C��f�l1:l��T�lF'4'S►:!1� <br />EHD43-06 6/112019 CCA <br />W : 13 <br />2— 1 C�_) 8 1�i WCL[./r',,Mi'PCRMI' <br />