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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 />IVUIN-KEFUNDABLE PERMIT www.sjgov.org/eno tJlY1KtJ 7 TEAR FF <br />JOB ADDRESS 1781 E Grant Line Rd CITY2IP Tracy / 95304 <br />CROSS STREET N Chrisman Rd APN 213-070-390-000 PARCEL SIZE 11.4 ACLAND USE APPLICATION # <br />OWNER NAME Marty Marilyn Trust PHONE <br />OWNER ADDRESS 1681 E Grant Line Road CITYISTATE/ZIP Tracy / CA / 95304 <br />Cuesta Geo, Inc. <br />ADDRESS 2709 Kapalua Court <br />PHONE (925)872-1248 <br />CITY/STATE/ZIP Fairfield / CA / 94534 <br />TRACTORICONSULTANT Cornerstone Earth Group PHONE (408) 245-4600 <br />TRACTOR/CONSULTANT ADDRESS 1259 Oakmead Parkway CITY/STATE/ZIP Sunnyvale / CA / 94085 <br />X C-57 C-61 0-09 Other NUMBER 1043431 EXPIRATION DATE 8/31/2022 <br />PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE - Domestic /Private - Irrigation/Agricultural Industrial - Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If different from Ovmer: Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well Replacement Well _ Well Alteration/Modification Other <br />7 Monitoring Well(s) # of wells Soil Boring(s) # or borings X Geotechnical 7 # of borings <br />7 Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />IVew rump _ rump rceplacemenc rump Kepalr Kalse vveu t,asmg <br />WELL CONSTRUCTION <br />Hallow Stem <br />Drilling Method Mud Rotary _ Air Rotary X Auger Cable Tool -- Push Point Other <br />Proposed Well Depth 5 to 50 ft Excavation 6.5 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />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 '_ -'> ft X Neat Cement (94 lb bagl5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped - Free Fall X Other Tremie Grout Retardant / Accelerator (name) <br />PEDESTAL Installed By _- Driller C Pump Contractor Other <br />D Concrete Pedestal ❑Dimensions: Width It Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible- Turbine Other HP Pump Set ft Standing Water Level ft <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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Digitally signed by Chris Krieg <br />SIGNED ...,. __ ��_._ �_.__ _ �. _.. TITLE DATE <br />,/ DEPARTMENT USE ONLY <br />Application Accepted By v � Date III JL b / Area S- r'�' t I Employee ID# <br />Grout Inspection By +�'�� L L- Date Z h y LZ 1 71 SPECIAL Well Permit <br />Pump Inspection By Date IJ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount to Permit/ Invoice # Well ID# <br />Codes Into Cash.Remitted ervice Request # <br />j124jU12 4 1A, i <br />EHD43-06 6/11/2019 Tf�,7 WELL [PUMP PERMIT <br />Vtir <br />X02, <br />�NTY <br />,ENT <br />