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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PynrErlRMIIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS a.G�V"• Lz mm e,rs CITYZlP {t.rCy r�J37� y <br /> CROSS STREET S.Lammers Road APN 251050090 and PARCEL S¢E VA LAND/USE APPLICATION# o <br /> -251-050-080 A <br /> OWNER NAME Intearal Partners Fundina.LLC PHONE 209.239-8400 M <br /> OWNER ADDRESS 1001 West Center Street CITY/STATEZP_Tracy,CA 95377 <br /> CONTRACTOR ENGEO Incorporated PHONE 562-472-4358 <br /> CONTRACTOR ADDRESS 17278 Golden Valley Parkway CITY/STATEZP Lathrop,CA 95330 <br /> SUBCONTRACTOR <br /> West Coast Exploration PHONE 916-799-8198 <br /> SUBCONTRACTOR ADDRESS 1396 BRIARWOOD AVE CITYISTATEZP Escalon CA 95320 <br /> LICENSE C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 01-03-2022 ; <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 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 Borings) #of borings X Geotechnical 9 #of borings <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 X Push Point Other <br /> Proposed Well Depth 25 ft Excavation 4 inches 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth n1 S ft X Neat Cement(94 Ib bagl5-10 gal water) Sand Cement sack mixR 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 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> . <br /> _, <br /> . <br /> pAy .P T <br /> D <br /> Vj <br /> s N ON Ill C UHTYA , <br /> EAT" E RI MENT <br /> I LL <br /> DEPARTMENT USE ONLY <br /> Application Accepted By_ "�1 Date S a Area S C Employee ID# As <br /> Grout Inspection By_ _ �r�' — Date_ ( 'g 12 SPECIAL W01I Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By. /Date—� —� Constructed W Depth ft <br /> COMMENTS �femml Ip e arlef-1 It Pfa(.,nC./I✓IILfZ�t7" L'Y]/'"�U�alei <br /> PE SCReceive Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted SepAce R s # <br /> 437.7 WFUCILUMI <br /> EHD 43-06 revised 4/14/18 3 d WELL/PUMP PERMIT <br />