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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 /> NON-REFUNDABLE PERMIT www.s ov org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS 1651 E Grant Line Rd CrrY21P Tracy/95304 <br /> s <br /> CROSS STREET N Chrisman Rd APN 213-070-410-COO PARCEL SIZE 6.3 AC LAND USE APPLICATION# <br /> OWNER NAME Marty Marilyn Trust PHONE !^ <br /> OWNER ADDRESS 1681 E Grant Line Road cm/STATE/ZIP Tracy/CA/95304 <br /> CONTRACTOR Middle Earth Geo Testing,Inc. PHONE (714)633-5025 <br /> CONTRACTOR ADDRESS 27639 Industrial Blvd CrrYISTATE/ZIP Hayward/CA/94545 <br /> SUBCONTRACTOR/CONSULTANT Cornerstone Earth Group PHONE (408)245-4600 <br /> SUBCONTRACTORICONSULTANT ADDRESS 1259 Oakmead Parkway CrY/STATE/ZIP Sunnyvale/CA/94085 <br /> LICENSE X C-57 U C-61 U D-09 U Other_ I NUMBER 899451 EXPIRATION DATE 6130/2023 <br /> BILLING PARTY: n OWNER D CONTRACTOR x SIUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(439 1)❑Dibromochioropropane(4392)n Arsenic(4393) <br /> INTENDED USE p Domestic/Private D Irrigation/Agricultural n Industrial U Water Quality Monitoring X Soil Sampling/Characterization <br /> n Public Water System <br /> If different from Owner. Water Syslam Neme Contact Name or Phone Number <br /> TYPE OF WORK U New Well n Replacement Well C Well Alterafio /Modification 0 Other <br /> O Monitoring Wells) #of wells [I Soil Boring(s)i <br /> #of borings X Geotechnical 5 if of badngs <br /> 2 Out-0l-Service Well U Out-Ol-Servic Well Renewal O Cross-Connection Repair <br /> C New Pump U Pump Replacement U Pum Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C Mud Rotary n Air Rotary U Auger Cable Tooli ❑Push Point X:] Other Cone Penetration Tests(1.5"Cone) <br /> Proposed Well Depth 50 tO 100 ft Excavation 1.5 in diameter C Open Bottom D Gravel Pack/Gravel Size In diameter <br /> U Conductor Casing in diameter / Conductor using Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched n Steel 11 Plastic n Stainless Steel C Other <br /> Grout Seal Depth —I iX) ft )�Neat Cement(94 lb bagl5-IC gal water) U Sand Cement sack m1x17 gal water <br /> ❑Bentonite(20%solids) i1 Other <br /> t Placement Method U Pumped n Free Fall X1 Oth <br /> Grouer Tremie rout ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller D Pump Contractor n Other <br /> ❑Concrete Pedestal UDimenslons:Width ft L nglh It Thick In ❑Christy Box U Stove Pipe <br /> PUMP L3Submerslbleu Turbine U Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION �1ND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND I REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AN CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP ION LAWS. <br /> MINIMUM I R A NCE NOTICE REQUIRED FOR S�PErCTI NS-PLEASE CALL(209)953-7697 Z <br /> SIGNED <br /> T DATE <br /> I <br /> ----------- <br /> ---- - ------ <br /> T <br /> O <br /> C NC <br /> r r <br /> IN <br /> ---------- ---- <br /> DEPARTMENT USE ONLY /� <br /> Application Accepted By e= Date /1. o bj Area S/7-0 r 1 Employee ID# /4--S <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date [I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cas Remitted Service Request# <br /> 37.d7 iso i o r 7 7 2 1 POD LI --�-'l <br /> EHD 43-06 6/11/2019 < /3 — L.- / I WELL(PUMP PERMn <br /> q r�( <br />