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4. <br />5�LLJ <br />W X <br />CL W <br />C <br />G � <br />w^ X <br />CL W <br />WELL/PUMP PERMIT <br />SAN Jo AOum Counrr ENVIRONMENTAL HEALvm DEPARTMEN- 1866 EA5T HAZFITON A-Nur - S-OCnTON CA 95205 •45232 1209] 468-3420 <br />NON-REFUNDABLE PERMIT www.Sjgov.org/ehd <br />,A M E N T U E NLY <br />Ile <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Bird Road, see site plan <br />ci—z,P <br />Tracy 95304 <br />CROSS STREET Grant Line Road APN <br />� Imps <br />LAID UW APRPLICATM R <br />OWNER NAME San Joaquin County, California <br />_ Date <br />PMose (209) 468-3000 <br />OWNER ADDRESS 1810 East Hazelton Avenue <br />CrrV19TA"1zr <br />Stockton, CA 95205 <br />Cale Crawford <br />CONTRACTOR <br />(209 684-7605 <br />Pm (209) <br />CONTRACTOR ADDRESS 17278 Golden Valley Parkway <br />caymAnji <br />Lathrop, CA 95330 <br />sueCONTRACTORICONSULTANTMiddle Earth Geo Testing, Inc <br />pipe. (714) 633-5025 <br />SUSCONTRACTOR/CONSULTANTADDRESS 954 North Lemon <br />Street CITYISTATP1zr Orange, CA 92867 <br />LICENSE XC -57 C-61 D-09 Other <br />NUMBER 899451 <br />ExPNtAlION DATE 8/8/2020 <br />BILLING PARTY: OWNER CONTRACTOR <br />SUSCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAmpuNG: General Mineral/Cdlform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Dome9bcJPrivate Inlgabon/Agricultural Industrial Water Quality Monnonng Soil SampingtCharactenzat!on <br />Public WaterSystem <br />M 011'"ll .— 0-1 PERM IT,CcrUd Nero or >rtone Numtr <br />TYPE OF WORM New Well Replacement WellryOlyiranon "( Other `- - t <br />Mon" Wallis) 0 of well SEX. Bc Yy s o,—'g' K Geotechnycal Sol n <br />Out -Of -Service Well Out-Of-Serv.ce Well Renewal CFoss-Connection Repan <br />Drilling Method MUD Rotary Air Rotary Auger Calle Triol XPush Poen! Other <br />Proposed Well Depth 50 ft Excavation _ _ in diameter Open Bottom Gravel PacwGravN Size _ in diameter <br />Conductor Casing in diameter Conductor Casing Depth h <br />Well Casing Diameter n Thickness/Gauge:ASTM Schad steel Plastic Stainless Steel Other <br />Grout Seal Depth 0 It %Neat Cement (94 Ib Dapv3-10 per wato Sand Cement sacci mix/? gal welter <br />Bentonite (20% soles) Other_ <br />Grout placement Method Pumpetl Free Fall Ottley Retardant I Accelerator (Mme) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions Width ft Len0 R ThN.9t In Christy Box Stow Pipe <br />INILP SutrTrersible Turbine Ottley HP Pun-!, Set It Stanorlg Water Level R <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />J OAQUIN C NTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE I$ <br />CURRENT AN ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS CO. NSATION LAWS. <br />SIGNED <br />Ata`E NOTICE REQUIRED <br />tilt <br />ISee attached for Site Pian I <br />19 953-769 <br />AYMENT <br />CEIVED <br />R 13 2020 <br />AQUIN COUNTY <br />RONMENTAL <br />DEPARTMENT <br />Application Accepted By <br />,A M E N T U E NLY <br />Ile <br />Area's Employee 109 01- S?` 4 0 -- <br />Grout Inspection By <br />Date <br />SPECIAL Well Permit <br />Pump Inspection By <br />_._ Date <br />WAIVER Received <br />Sol Boring Inspection By <br />_ Date <br />Constructod Well Depth R <br />COMMENTS <br />E-1)13-06 6 112019 INELL Nt w nERMn <br />M <br />TX m <br />v <br />M <br />