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WELL/PU SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT NON-REFUNDABLEiPERMIT WWW. jc i JOB ADDRESS 19401 S Austin Road CROSS STREET Graves Road 57 F' Y ;' (I APN 228-020-39 OWNER NAME Pizzi Partnership c/o Elaine Scadden OWNERADDRESS 1685 MCBAIN AVE CONTRACTOR Middle Cj Earth Geo Testing, Inc. 35 CONTRACTOR ADDRESS 1 5 Ca66 - 0 Vd . SUBCONTRACTOR/CONSULTANT Cornerstone Earth Group SUBCONTRACTOR/CONSULTANTADDRESS 1259 Oakmead P LICENSE X C-57 J C-61 D-09 Other BILLING PARTY: U OWNER J CONTRACTOR P PERMIT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 4683420 ,.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED Crr/ZtP Manteca / 95336 )00 PARCEL SIZE 23 AC LAND USE APPLICATION # 4� 2l R1 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (439 ) 11 Dib cmochloropropane (4392) i_! Arsenic (4393) INTENDED USE ❑ Domestic/Private U Irrigation/Agricultural —i Industrial ❑ Waker Quality Monitoring X Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water Svstem Name I Contact Name or Phone Number TYPE OF WORK ❑ New Well I I Replacement Well 1:J Well Alteratio p/Modification I Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s)I! # of borings X Geotechnical 8 # of borings ❑ Out -Of -Service Well ❑ Out -Of -Servide Well Renewal Cross -Connection Repair ❑ New Pump i Pump Replacement 1 Pump Repair' Raise Well Casing WELL CONSTRUCTION Hollow Stem Drilling Method , Mud Rotary Air Rotary L� Auger L= Cable Tool L Push Point Other Proposed Well Depth50 to 100 ft Excavation 1.5 in diameter Open Bottom 1 Gravel Pack/Gravel Size in diameter D Conductor Casing in diameter / Conductor Easing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched i iJ Steel I i Plastic i 1 Stainless Steel 11 Other Grout Seal Depth Sr-) .- I J J ft X; Neat Cement (94 lb bag/5-1d gal water) U Sand Cement sack mix/7 gal water 7 Bentonite (20% solids) Other Grout Placement Method L Pumped Free Fall X Other Tremae Grout Retardant / Accelerator (name) PEDESTAL Installed By Driller Pump Contractor Other Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box Stove Pipe PUMP _ Submersible—, Turbine Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL DEPARTMENT USE ONLY Application Accepted By L Date /2/4;,l Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS Date Date Date 7i 2 Area S ed Employee ID# A ❑ SPECIAL Well Permit [] WAIVER Received Constructed Well Depth ft PE SC Received Check#/ Amount Permit/ Codes Info Cash Remitted Date ervice Request # Invoice # Well ID# y 3-7a 1_ 0 500 EHD43-06 6/11/2019 - ' ��CC-/ �� WELL/PUMP PERMIT T PHONE CITY/STATE/ZIP SAN JOSE / CA / 95125 PHONE (714)633-5025 CrrY/STATE/ZIP Hayward / CA / 94545 PHONE (408) 245-4600 CITY/STATE/ZIP Sunnyvale / CA / 94085 899451 EXPIRATION DATE 6/30/2023 )R/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (439 ) 11 Dib cmochloropropane (4392) i_! Arsenic (4393) INTENDED USE ❑ Domestic/Private U Irrigation/Agricultural —i Industrial ❑ Waker Quality Monitoring X Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water Svstem Name I Contact Name or Phone Number TYPE OF WORK ❑ New Well I I Replacement Well 1:J Well Alteratio p/Modification I Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s)I! # of borings X Geotechnical 8 # of borings ❑ Out -Of -Service Well ❑ Out -Of -Servide Well Renewal Cross -Connection Repair ❑ New Pump i Pump Replacement 1 Pump Repair' Raise Well Casing WELL CONSTRUCTION Hollow Stem Drilling Method , Mud Rotary Air Rotary L� Auger L= Cable Tool L Push Point Other Proposed Well Depth50 to 100 ft Excavation 1.5 in diameter Open Bottom 1 Gravel Pack/Gravel Size in diameter D Conductor Casing in diameter / Conductor Easing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched i iJ Steel I i Plastic i 1 Stainless Steel 11 Other Grout Seal Depth Sr-) .- I J J ft X; Neat Cement (94 lb bag/5-1d gal water) U Sand Cement sack mix/7 gal water 7 Bentonite (20% solids) Other Grout Placement Method L Pumped Free Fall X Other Tremae Grout Retardant / Accelerator (name) PEDESTAL Installed By Driller Pump Contractor Other Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box Stove Pipe PUMP _ Submersible—, Turbine Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL DEPARTMENT USE ONLY Application Accepted By L Date /2/4;,l Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS Date Date Date 7i 2 Area S ed Employee ID# A ❑ SPECIAL Well Permit [] WAIVER Received Constructed Well Depth ft PE SC Received Check#/ Amount Permit/ Codes Info Cash Remitted Date ervice Request # Invoice # Well ID# y 3-7a 1_ 0 500 EHD43-06 6/11/2019 - ' ��CC-/ �� WELL/PUMP PERMIT T