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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 <br />JOB ADDRESS ( 1 °.+ 0 I W Schulte Road <br />CROSS STREET Quality Road <br />OWNER NAME Prologis <br />OWNER ADDRESS 3353 Gateway Blvd. <br />ENGEO <br />www.sjgov.org/ena txh'IKt, 7 YEAR FROM DATE ISSUED <br />CITY/LP Tracy, CA 95377 <br />209-250-10,209-250-37, ` <br />APN209-240-36, 209-240-37PARCEL SIZE I014LAND USE APPLICATION# <br />ADDRESS 17278 Golden Valley Pkwy. <br />SUBCONTRACTORICONSULTANT West Coast Exploration <br />SUBCONTRACTORICONSULTANT ADDRESS P.O. Box 133 <br />LICENSE x C-57 C-61 0-09 Other <br />BILLING PARTY: OWNER xCONTRACTOR <br />CITY/STATE21P Fremont, CA 94538 <br />PHONE 209-835-0610 <br />CITYISTATE21P Lathrop, CA 95330 <br />209-985-7541 <br />CITY/STATE21P Escalon, CA 95320 <br />NUMBER 870761 EXPIRATION DATE 01/31/2022 <br />SUBCONTRACTOR/CONSULTANT <br />DOMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Inigation/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) a of Ings x Geotechnical 10 If of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Kame well <br />Drilling Method Mud Rotary Air Rotary x Auger Cable Tool Push Point Other <br />Proposed Well Depth 30 ft Excavation 4 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth 3Q it x Neat Cement (941b bag/5-10 gal water) Sand Cement sack mixl7 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 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 />NINIMUM4$HOIUIR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED- '- V�✓ :. rr Ji�1.�'_:ir: f TITLE Project Engineer DATE 08/31/2021 <br />rn <br />g <br />71 <br />m <br />N <br />DEPARTMENT US ONLY An <br />// <br />Application Accepted By v Data �b Area s "1 Employee ID# i <br />Grout Inspection By Data O SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection B r Date Constructed Well Depth ft <br />C� <br />COMMENTS _ lL'YMN►�'e D)T' � � be �:sFC iY PPt�Pf �T7 FFR T nr �iOtJ]'t�' S^I C ;S <br />L't���3R�l�Il, �,/:��■ %�III��LilfF7 'L'■ln ► � i '!�'Jir�� <br />EHD43-06 6/11/2019 �/ WELL /PUMP PERMIT <br />