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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 />NUN -REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1651 E Grant Line Rd <br />CITY2IP Tracy / 95304 <br />CROSS STREET N Chrisman Rd APN 213-070-410-000 PARCEL SaE6.3 AC LAND USE APPLICATION # <br />OWNER NAME Marty Marilyn Trust <br />PHONE <br />OWNER ADDRESS 1681 E Grant Line Road <br />CITY/STATE/ZIP Tracy / CA 195304 <br />CONTRACTOR Cuesta Geo, Inc. <br />PHONE (925) 872-1248 <br />CONTRACTOR ADDRESS 2709 Kapalua Court <br />CITY/STATE2IP Fairfield / CA / 94534 <br />SUBCONTRACTOR/CONSULTANT Cornerstone Earth Group <br />PHONE (408) 245-4600 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1259 Oakmead Parkway <br />CITY/STATE/ZIP Sunnyvale / CA / 94085 <br />LICENSE X C-57 C-61 D-09 Other <br />NUMBER 1043431 EXPIRATION DATE 8/31/2022 <br />BILLING PARTY: .OWNER CONTRACTOR <br />X SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General MinerallColiform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NITENDED USE - DomesticlPrivate Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br />_ Public Water System <br />M Cifferent from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) n or borings X Geotechnical 5 # or borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />I—W rUlll r.11l rte—e..ICIiI 1.111 —p— ldlbC -11 l dSlll <br />WELL CONST RUCTION Hollow Stem <br />Drilling Method Mud Rotary Air Rotary 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 Ib bag/5-10 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 Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible - Turbine Other HP Pump Set R Standing Water Level It <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 />,% %DEPARTMENT USE ONLY <br />Application Accepted By v `-- Date 2 �� Area r /�.' Employee ID# t <br />Grout Inspection By -_vim' --Z Date/'rll r ❑ SPECIA( Well Permit <br />Pump Inspection By Date LI WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth tt <br />COMMENTS. __ <br />PE Sc Received Check#/ <br />Codes Info B Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice 9 Well ID# <br />ervice Request # <br />f ? 7u <br />it _ r <br />F <br />'\ Z <br />EHD 47-06 6/712019 ( / g �W --WELL /PUMP PERMIT <br />VtO <br />7 <br />