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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1781 E Grant Line Rd Crrv/ZIP Tracy / 95304 <br />CROSS STREET N Chrisman Rd APN 213-070-390-000 PARCEL SIZE 11.4 ACLAND USE APPLICATION # <br />i <br />OWNER NAME Marty Marilyn Trust PHONE <br />OWNER ADDRESS 1681 E Grant Line Roadi CrTY/STATE/ZIP Tracy / CA / 95304 <br />CONTRACTOR Middle Earth Geo Testing, Inc. PHONE (714) 633-5025 <br />CONTRACTOR ADDRESS 27639 Industrial Blvd CrrY/STATEIZIP Hayward / CA / 94545 <br />SUBCONTRACTORICONSULTANT Cornerstone Earth Group i PHONE (408) 245-4600 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1259 Oakmead Parkway CITY/STATE/ZIP Sunnyvale / CA / 94085 <br />LICENSE X C-57 ❑ C-61 a D-09 _j Other I NUMBER 899451 ExPIRATION DATE 6/30/2023 <br />BILLING PARTY: LJ OWNER _J CONTRACTOR X S BCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391 U Dibromochloropropane (4392) I i Arsenic (4393) <br />INTENDED USE a Domestic/Private Irrigation/Agricultural J Industrial u Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name I Contact Name or Phone Number <br />i <br />TYPE OF WORK ji New Well Replacement Well A Well Alteration/Modification Other <br /># of borings Geotechnical 5 # of borings <br />❑ Monitoring Well(s) # of wells Ll Soil Boring(s) X <br />❑ Out -Of -Service Well D Out -Of -Service Well Renewal Cross -Connection Repair <br />❑ New Pump L; Pump Replacement U Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Cone Penetration Tests (1.5" Cone) <br />Drilling Method C Mud Rotary Air Rotary ! Auger L Cable Tool ! J Push Point Other <br />Proposed Well Depth 50 to 100 ftExclavation 1.5 in diameter G Open Bottom Gravel Pack/Gravel Size in diameter <br />7 Conductor Casing !in diameter / Conductor basing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched wateI I Steel ❑ Plastic Stainless Steel Other <br />Grout Seal Depth 7 lot) ft X Neat Cement (94 Ib bag/5-10Iga/ r) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method 11-1 Pumped i 1 Free Fall X Other Tremie Grout ;; Retardant / Accelerator (name) <br />PEDESTAL Installed By "1 Driller F1 Pump Contractor D, Other <br />n Concrete Pedestal LDimensions: Width ft Lehgth ft Thick in a Christy Box Stove Pipe <br />PUMP Submersible❑ Turbine Other HP Pump Set ft Standing Water Level ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION 4ND 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 ACT ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPEN7ioftL <br />MINIMUMICE REQUIRED IFORIN ECTIONS - PLE�A�S�(E� CALL (209) 953-7697 <br />SIGNED TITLEl\��1 �Y 1 DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By 1 Z_ Date <br />Grout Inspection By .�-"' c_ Date <br />Pump Inspection By Date J <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />4 <br />m <br />D <br />0 <br />0 <br />m <br />m <br />N <br />y <br />Area 5Tri Employee ID# <br />❑ SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />NT <br />C�_D <br />I <br />PE <br />Codes <br />SC Received Check#I <br />Info B Cash <br />Amount at <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />y3 7/ <br />s O <br />O 7li-2 <br />�— <br />EHD 43-06 6/11/2019 0 41 6 / ! 12—l"')/ WELL /PUMP PERMIT <br />