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WELL/ U <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT WWW SjC <br />JOB ADDRESS 19511 S Austin Road <br />CROSS STREET Graves Road ST F T C1'1 APN 228-050102 <br />OWNER NAME Pizzi Partnership c/o Elaine Scadden <br />OWNER ADDRESS 1685 MCBAIN AVE <br />P PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 4683420 <br />,.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP Manteca / 95336 <br />)00 PARCEL SIZE 23 AC LAND USE APPLICATION # <br />CITY/STATE/ZIP <br />PHONE <br />SAN JOSE / CA / 95125 <br />CONTRACTOR Middle Earth Geo Testing, Inc. I PHONE (714) 633-5025 <br />CONTRACTOR ADDRESS 2_35'15 Ca �! CITY/STATE/ZIP Hayward / CA / 94545 <br />SUBCONTRACTOR/CONSULTANT Cornerstone Earth Group PHONE (408) 245-4600 <br />SUBCONTRACTOR/CONIULTANTADDRESS 1259 Oakmead Parkw�y CITY/STATE/ZIP Sunnyvale / CA / 94085 <br />LICENSE X C-57 U C-61 ❑ D-09 �, Other NUMBER 899451 EXPIRATION DATE 6/30/2023 <br />BILLING PARTY: OWNER - CONTRACTOR I X SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:, I General Mineral/Coliform Bacteria(4391) ❑ Diblromochloropropane (4392) .1 Arsenic (4393) <br />INTENDED USE Li Domestic/Private C Irrigation/Agricultural ❑ Inddstriall D Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System I <br />If different from Owner: Water System Name 1 Contact Name or Phone Number <br />TYPE OF WORK New Well i i Replacement Well J Well Alteration/Modification 1.1 Other <br />❑ Monitoring Well(s) # of wells ri Soil Borin s' # of borings 5 # of borings <br />9( X Geotechnical <br />i_i Out -Of -Service Well ❑ Out -Of -Sere+ Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump :Pump Replacement Pump Re air ❑ Raise Well Casing <br />WELL CONSTRUCTION i <br />Hollow Stem <br />Drilling Method D Mutt Rotary L Air Rotary _. Auger CableiToof ❑ Ptjsh Point _ Other <br />Proposed Well Depth 50 to 100 ft Excavation 1.5 inidiarrieter C Open Bottom E Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor C-asing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM SchedI . Steel i Plastic C; Stainless Steel LI Other <br />Grout Seal Depth ft X Neat Cement (94 Ib bag/5-1`1 gal watj Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other i <br />Grout Placement Method I Pumped [ i Free Fall X Other Tremie Grout Retardant /Accelerator (name) <br />PEDESTAL Installed By Driller � Pump Contractor Other <br />Concrete Pedestal VDimensions Width ft Length ft Thick n Christy Box Stove Pipe <br />PUMP _Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY DINANCES, STATE LAWS, AND RULES AND j2EGULgTIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACT H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENS S. <br />Nil hJlh'1t1V :,"' 'i; NOTICE REQUWED OR SPECTIONS -PLEASE GALL (209) 953-7697 <br />SIGNED � TITL M MI'" DATE la 120 Z i <br />DEPARTMENT USE ONLY <br />771 <br />> J <br />Application Accepted By 1, Date f z/OE,/a I <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area ` C%�9 Employee ID# <br />C SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />T <br />D <br />0 <br />0 <br />m <br />m <br />m <br />PE SC Received Check#/ Amount <br />Codes Info By Ca h Remitted <br />Permit! WellID# <br />Date Service Request # Invoice #„ <br />37a ►so <br />EHD 43-06 6/11/2019 �. ����s/ ✓�/ WELL/PUMP PERMIT <br />