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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95265.6232 (299)4683420 <br />IVUIV-KEFUNDABLE PERMIT www.sjgov.org/ena r-Al"lKtS 7 YEAR FROM DATE ISSUED <br />JOB ADDRESS 9409 W Arbor Avenue Crrr/Zip Tracy/95304 <br />CROSS STREET S Holly Road APN 212-16-020 PARCEL SIZE 1 1 ® LAND USE APPDCAmON # n/a <br />OWNER NAME Phelan Development PHONE n/a <br />OWNER ADDRESS 450 Newport Center Drive, Suite 230 CITY/STATFJZIp Newport Beach/CA/92660 <br />CONTRACTOR ENGEO I ncorporated PHONE 209-305-0610 <br />CONTRACTOR ADDRESS 17278 Golden Valley Parkway CITY/STATE/Zlp Lathrop/CA/95330 <br />SUBCONTRACTOR/CONSULTANT West Coast Exploration PHONE We <br />SUBCONTRACTOR/CONSULTANT ADDRESS P.O. Box 133 CITY/STATE/ZIp Escalon/CA/95320 <br />LICENSE OC -57 []C-61 ❑ D-09 []Other NUMBER 870761 EXPIRATION <br />BILLING PARTY: TOWNER ❑✓ CONTRACTOR [—]SUBCONTRACTOR/CONSULTANT <br />1131/22 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ✓ 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 />❑MonitoringWell(s) #of wells []SoilBoring(s) 4 o borings [j]Geotechnical 2 cfhorings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair D Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger D Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 30 ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth Full Length ft ❑✓ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />:] Bentonite(20%solids) ❑ Other <br />Grout Placement Method ❑ Pumped OFreeFall ❑ Other Tremie (if under GW) ❑ 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 1 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADY.A ICF�Ij�,jIgP REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />w <br />g <br />0 <br />r <br />b <br />DEPARTMENT USE NLY <br />Application Accepted By Date J f / Area S % Employee ID# <br />Grout Inspection By Date I % 117 1 ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />C'E��%7►1/,��L'L'�%�iYiE�II9�1r��.jriI�L■��1►►�� <br />EHD43-06 6/11/2019 :YELL 'JI."' 117 <br />