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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 />NON-REFUNDABLE PERMIT www.sjgov.orgiena tAIJ[Ktb 'I YEAR FROM UATE ISSUED <br />JOB ADDRESS 1781 E Grant Line Rd CITY/ZIP Tracy / 95304 <br />CROSS STREET N Chrisman Rd APN 213-070-390-000 PARCEL SIZE 11.4 ACLAND USE APPLICATION # <br />OWNER NAME Marty Marilyn Trust PHONE <br />OWNERADDRESS 1681 E Grant Line Road <br />CONTRACTOR <br />Middle Earth Geo Testing, Inc. <br />CONTRACTOR ADDRESS 27639 Industrial Blvd <br />CITY/STATE/ZIP Tracy / CA / 95304 <br />PHONE (714) 633-5025 <br />CITY/STATE/ZIP Hayward /CA/94545 <br />SUBCONTRACTOR/CONSULTANT Cornerstone Earth Group PHONE 1408) 245-4600 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1259 Oakmead Parkway CITY/STATE/ZIP Sunnyvale / CA / 94085 <br />LICENSE X C-57 C-61 D-09 ❑ Other <br />BILLING PARTY: 0 OWNER _ CONTRACTOR <br />NUMBER <br />899451 EXPIRATION DATE 6/30/2023 <br />X SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: iGeneral Mineral/Coliform Bacteria (4391) Cl Dibromochloropropane (4392) i_j Arsenic (4393) <br />INTENDED USE Domestic/Private _ Irrigation/Agricultural L Industrial ❑ Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well D Replacement Well i_, Well Alteration/Modification _; Other <br />Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings X Geotechnical 4 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal ;j Cross -Connection Repair <br />New Pum =7 Pump Replacement C Pump Repair ❑Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Li Mud Rotary <br />Air Rotary I Auger Cable Tool C, Push Point Other Cone Penetration Tests (1.5" Cone) <br />Proposed Well Depth 50 ft Excavation 1.5 in diameter i1 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 Sched : SteelF1 Plastic I"i Stainless Steel 1 Other <br />Grout Seal Depth ft K Neat Cement (94 lb bag/5-10 gal water) _ Sand Cement sack mix17 gal water <br />Bentonite (20% solids) n Other <br />Grout Placement Method 17 Pumped L; Free Fall X Other Tremie Grout Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller I) Pump Contractor 1 Other <br />�j Concrete Pedestal _Dimensions: Width ft Length ft Thick in Christy Box _ Stove Pipe <br />PUMP -i Submersible L Turbine >r 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 WRH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSAT116N WS. <br />MINIMUM 48 H DV NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7[697 <br />SIGNED TITLE I& J DATE 1 1 I C <br />T, <br />m <br />D <br />0 <br />0 <br />m <br />m <br />inN <br />DEPARTMENT USE ONLY <br />Q �7l17 <br />Application Accepted By d Date (/ !� C Z Area ��gmployee ID# <br />_A�r <br />- yGrout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By _ Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS C,<- -h <br />Constructed Wel <br />0 <br />ft <br />PE SC <br />C des Info <br />Received Check#/ <br />By Cash <br />Amount Permit/ IPA <br />Remitted Date Service Request # Invoice <br />II ID# <br />MENTI <br />t <br />�� 1 G� RECEIVED <br />IV rail <br />MAR <br />18 2022 <br />SAN JUIN <br />COUNTY <br />ENVIR <br />NMENTAL <br />