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r l0 t tiw7w*►s v/ �71 WELL/PUM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT WWW.sjg0V1org1ehd EXPIRES 1 YEAR FROM DATE ISSUED N JOB ADDRESS 1651 E Grant Line Rd CITYlZIP Tracy/95304 m D CROSS STREET N Chrisman Rd APN 213-070-410-000 PARCEL SIZE 6.3 AC LAND USE APPLICATION# z m OWNER NAME Marry Marilyn Trust PHONE v! OWNER ADDRESS 1681 E Grant Line Road Crrv/sTATE/ZIP Tracy/CA/95304 CONTRACTOR Middle Earth Geo Testing, Inc. PHONE (714)633-5025 CONTRACTOR ADDRESS 27639 Industrial Blvd CrIY/STATE/ZIP Hayward/CA/94545 SUBCONTRACTOR/CONSULTANT Cornerstone Earth Group T- - PHONE (408)245-4600 SUBCONTRACTORICONSULTANT ADDRESS 1259 Oakmead Parkway CITY/STATE/ZIP Sunnyvale/CA/94085 LICENSE X C-57 L C-61 D-09 Other NUMBER 899451 EXPIRATION DATE 6/30/2023 BILLING PARTY: OWNER -CONTRACTOR X SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: ':I General MineraUColiform Bacteria(439 1)U Dibromochloropropane(4392)i j Arsenic(4393) INTENDED USE ❑ Domestic/Private Irrigation/Agricultural Industrial U Water Quality Monitoring X Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well IReplacement Well ❑ Well Alteration/Modification I Other U Monitoring Wells) #of wells ri Soil Boring(s) #of borings Geotechnical 55 #of borings P Out-Of-Service Well i Out-Of-Servica Well Renewal i! Cross-Connection Repair New Pump Pump Replacement Pump Repair J Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary Air Rotary _ Auger _ Cable Tool Push Point X' Other Cone Penetration Tests (1.5 Cone) Proposed Well Depth 50 to 100 ft Excavation 1.5 in diarrueter _ Open Bottom —: Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched I :? Steel I I Plastic i 1 Stainless Steel Other Grout Seal Depth Z7_I gj ft X: Neat Cement(94 lb bag/5-1(I gal water) U Sand Cement sack mix/7 gal water I Bentonite(20%solids) Other Grout Placement Method - Pumped !1 Free Fall X Other Tremie Grout r1 Retardant/Accelerator(name) PEDESTAL Installed By I Driller Pump Contractor 1 O her Li Concrete Pedestal UDimensions:Width ft Length ft Thick in Christy Box U Stove Pipe PUMP a Submersibleu Turbine Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AN CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMP ION LAWS. MINIMUM RANCE NOTICE REQUIRE r� FORqNSPECTI NS -PLEASE CALL (209) 953-7697 Z SIGNED T E `M"• DATE / I ---------------- � I I I S O � NC r r I I I l l l l l l l l l l l l l l l l l l i l l i 1 1 i i—I i l l l l l l l l l l l l l l DEPARTMENT USE ONLY Application Accepted By Date /2- oz ' J Area /c7 c I Employee ID# A i Grout Inspection By L`L Date �9 �� d' ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Cas Remitted Service Re uest# 37a f-'�-O j o4 l2 5 21 EHD 43-06 6/11/2019 ` / �{ ��1 J' /2— I WELL/PUMP PERMIT