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WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.siaov.ora/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 11428 Clover Road CITYIZIP _Tracy, CA 95376 <br />CROSS STREET N. Tracy Blvd. APN 214-050-05 & -03 PARCEL SIZE 10 ac LAND USE APPLICATION # <br />OWNER NAME Sumayya LLC PHONE (510) 449-1573 <br />OWNER ADDRESS 38765 Mission Blvd. CITY/STATE/LP Fremont. CA 94536 <br />CONTRACTOR West Coast Exploration, Inc. PHONE (209) 985-7541 <br />CONTRACTOR ADDRESS P.O. Box 133 CITY/STATE2IP Escalon, CA 95320 <br />SUBCONTRACTOR/CONSULTANT Stevens, Ferrone & Bailey Engineering Company, Inc. PHONE (925) 688-1001 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1600 Willow Pass Court CITY/STATEMP Concord, CA 94520 <br />LICENSE "( C-57 C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 01 /31/2022 <br />BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTORMONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) . j Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private Irrigation/Agricultural Industrial -1 Water Quality Monitoring X Soil Sampling/Characterization <br />❑ Public Water System <br />If dlflerenl from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well Replacement Well Well Alteration/Modification Other <br />7 Monitoring Wells) # of wells '(Soil Boring(s) 6 # of borings Geotechnical k of borings <br />7 Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other Sq N ]. <br />Proposed Well Depth 20 & 40 ft Excavation 4 in diameter Open Bottom Gravel Pack/Gravel Size_/�i <br />Conductor Casing N/A in diameter / Conductor Casing Depth N/A ft �ALTIH <br />Well Casing Diameter hLL in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 20 & 40 ft X Neal Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other Trc if 9— ,.a .IIQF <br />Grout Placement Method Pumped I Free Fall X Other is encountered ❑ Retardant / Accelerator (name) <br />PEDESTAL N/A Installed By Driller Pump Contractor Other <br />D Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP NIA ❑ 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM/48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED / J _- TITLE Owner / Operator DATE 01/17/2021 <br />DEPARTMENT USE ONLY /I <br />Application Accepted By ��— L"V Dale f i O ;Area �'/ ' (! Employee ID# <br />Grout Inspection By n Date %L 7 SPECIAL Well Permit <br />Pump Inspection By ale WAIVER Received <br />Soil Boring Inspection By Day Const ted WeJI Depth ft <br />AM NTS Ifel'"IP -FJ i,c `rte i>t <br />W <br />D <br />0 <br />m <br />N <br />NjENr <br />E� QED <br />V 19 20 <br />22 <br />?L//N C <br />PMFNTA �NTY <br />gRTMENT <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ <br />ash <br />Amount Dat Penult/ Invoice # Well ID# <br />Remitted Service Re ues # <br />r7 <br />(; <br />5ct _ <br />f 1� I <br />EHD 43-06 6111x2019 // /! —,)� 1:3 <br />� / / / / 1;-3 WELL ]PUMP PERMIT <br />