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t WELUPUMP 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 /> 19401 S Austin Road Manteca/95336 <br /> JOB ADDRESS CITYIZIP m <br /> f�1 � <br /> CROSS STREET Graves Road -S, 41(\pN 228-020'390'000 PARCEL$RE 23 AC LAND USE APPLICATION# O <br /> A <br /> OWNER NAME Pizzi Partnership c/o Elaine Scadden PHONE H <br /> OWNER ADDRESS 1685 MCBAIN AVE CITY/STATE/ZIP SAN JOSE/CA/95125 <br /> CONTRACTOR Cuesta Geo,Inc. PHONE (925)872-1248 <br /> CONTRACTOR ADDRESS 2709 Kapalua Court CITY/STATE/zIP Fairfield/CA/94534 <br /> SUBCONTRACTOR/CONSULTANT Cornerstone Earth Group PHONE (408)245-4600 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1259 Oakmead Parkway CITY/STATE/ZIP Sunnyvale/CA 194085 <br /> LICENSE X C-57 C-61 0-09 Other NUMBER 1043431 EXPIRATION DATE 8/31/2022 <br /> BILLING 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 New Well _ Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) #of borings X Geotechnical 5 #of borings <br /> 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 Hollow Stem <br /> Drilling Method Mud Rotary Air Rotary X Auger -Cable Tool Push Point Other <br /> Proposed Well Depth 25 to 40 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 zIS--X13 ft X Neat Cement(94 lb 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 Tremle Grout - Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length it Thick in Christy Box -Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It 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 /> Digitally signed by Chris Krieg <br /> SIGNED DN cndhris Kri---CC n TITLE DATE <br /> us <br /> Fc MINT <br /> C <br /> 06 <br /> ?421 <br /> Q(J/N <br /> F aRT��NTY <br /> 17 1 1 1M&NT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Nt l c I Area `1� Employee ID# �? <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date / t/�� ❑ WAIVER Received <br /> Soil Boring Inspection By Date�eriri�`_ Constructed Well Depth ft <br /> COMMENTS `C7 <br /> PE SC Received Check#/ Amount at Permit/ Invoice# Well ID# <br /> Codes Info DyIn Ca h Remitted Service est# <br /> 3 <br /> EHD13-06 6/112019 �^ // //� WELL/PUMP PERMIT <br />