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WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE' -TON AVENUE- STOCKTON CA 95205-6232(209)4U-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES i YEAR FROM DATE ISSUED <br />1OB ADDRESS A <br />CROSS STREET_ <br />DINNER NAME <br />DWNER ADDRESS <br />CONTRACTOR <br />Paradise Road CrrYZP Lathrop, CA 95330 <br />Stewart Road APN 21312006 PARCEL 5¢E 468.61 LAND USE APPLICATION # <br />River Islands Development, LLC PHONE 209-879-7900 <br />73 Stewart Road CITYISTATEMP Lathrop, CA 95330 <br />West Coast Exploration PHONE 209-985-7541 <br />CONTRACTOR ADDRESS <br />BUacONTRACTORiCONS <br />BuecoNTRACToR/Cous <br />LICENSE O(C-57 <br />BILLING PARTY: <br />PO Box 113 CfT/STATEMP Escalon, CA 95320 <br />TANT ENGEO Incorporated Osedorc@engeo.com) PHONE 925-719-0822 <br />.TANT ADDRESS 17278 Golden Valley Parkway CITYISTATEZP Lathrop, CA 95330 <br />D C-61 O D-09 0 Other NUMBER 70761 EXPIRATION DATE 01/31/2022 <br />0 OWNER 0 CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />Dounm WBLLSANPUNG: D General Mlneral/Colfform Bacteria (4391) D Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE D Domestic/Private ❑ Irrigation/Agricultural O Industrial D Water Quality Monitoring D Soil SamplinglCharacterizabon 1 <br />0 Public Water System <br />N afferent Iron Owner: ':,star System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well O Replacement Well 7 Well AlterationlModTcation D Other <br />D Monitoring Weil(s) #of wells Soil Boring(s) trof bmrvd° CXGeotechnieal tof borings <br />D Out -Of -Service Well Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />D New Pump D Pump Replacement n Pump Repair ❑ Raise Well Casing <br />Drilling Method I'. Mud Rotary D Air Rotary i5 Auger i] Cable Tool .7 Push Point 'T Other <br />Proposed Well Depth 30 It Excavation 4 In diameter C: Open Bottom D Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter I Conductor Casing Depth R <br />Well Casing Diameter _ In ThicknesslGauge/ASTM Schad :. Steel ❑ Plastic D Stainless Steel D Other <br />Grout Seal Depth 30 ft IXNeat Cement (94 1b bag15-10 gal wafer) C Sand Cement sock m1x17 gal water <br />!1 Bentonite (20h solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall XOthef tremae C Retardant/ Accelerator (name) <br />�PEDESTAL Installed By C Driller "'Pump Contractor D Other <br />_ Concrete Pedestal ^]Dlmensiorls: Width R Length ft Thick Nt+ O Christy Box D Stow Pipe <br />-AA----___....i. --------- <br />FPuaP Submersible Turbine Other HP Pump Set ft Standing Water Level <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 />SIGNED Jason Sedore TITLE Staff Geologist DATE 09/29/2021 <br />�y7 / DEPARTMENT USE ONLY <br />Application Accepted By Date �0 S i Area S 4f 4 t O Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By \\ .,,�,/��Date r WAIVER Received <br />/�- <br />Soil Boring Inspection By = J� 1 " ' ,O to U ✓ Constructed Well Depth R <br />COMMENTS <br />PE <br />Codes <br />37a <br />SC Received C <br />IMO <br />-o - <br />Amount 2i Permit/ Invoice # Well ID# <br />Remitted Service us t # <br />- <br />EHO4308 6011=19 <br />WELL R'uAP PERMrT <br />IENT <br />I VED <br />20?1 <br />NTA NT <br />t Tr"EN T <br />