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`1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 17350 Bethany Road&Adjacent parcel east CITY/ZIP Mountain House,CA 95391 m D CROSS STREET Wicklund Road&Bryon Road APN 20915030&20915027 PARCEL SIZE"4O acres LAND USE APPLICATION# o m m O4NNFR NnMG PHONE Amanjit Sandhu CP :Siva Saini 209-834-6242-- Contact Person: ---_-_--_—. - _ N OWNER ADDRESS 3972 W.Durham Ferry Road CITY/STATE/ZIP Tracy,CA 95304-8836 CONTRACTOR ANS Geo,Inc. Contact Person:Thileepan Rajah PHONE 908-754-8800 CONTRACTOR ADDRESS 14425 Falcon Head Blvd.Building E. CITY/STATE/ZIP Austin,TX 78738 SUBCONTRACTOR Clear Heart Drilling,Inc. Contact Person:Amber Pearson PHONE 707-568-6095 SUBCONTRACTOR ADDRESS 555 West College Ave,STE.B, CITY/STATE/ZIP Santa Rosa,CA 95401 LICENSE X C-57 ❑ C-61 ❑ D-09 Other NUMBER 780357 EXPIRATION DATE 6/30/2023 X DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural Industrial ❑Water Quality Monitoring x Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well ❑ Replacement Well Well Alteration/Modification Other LL Monitoring Well(s)_ _#of wells I Soil Boring(s) #of borings x Geotechnical 14 #of borings 0 Out-Of-Service Well x ❑ Out-Of-Service Well Renewal Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair Raise Well Casing WELL CONSTRUCTION (Temporary Wells to take groundwater level readings,which will removed prior to mobilizing off site.) Drilling Method Mud Rotary i Air Rotary 19 Auger Cable Tool Push Point Other Proposed Well Depth 50 ft Excavation 4 in diameter x Open Bottom Gravel Pack/Gravel Size N/A in diameter ❑ Conductor Casing N/A in diameter / Conductor Casing Depth N/A ft Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched 40 Steel I Plastic Stainless Steel ® Other PVC Grout Seal Depth 100/50/15 ft N Neat Cement(94/b baa/5-10 pal water) 0 Sand Cement sack mix/7 gal water Bentonite(20%solids) ® Other Cement Grout with Bentonite 'mi)' +n a Yip rrl SS J-10*41 y oium P Grout Placement Method N Pumped Free Fall I Other Tremie Grouted Retardant/Accelerator(name) PEDESTAL N/A Installed By ❑ Driller Pump Contractor ❑ Other Concrete Pedestal Dimensions:Width ft Length ft Thick �in ❑ Christy Box Stove Pipe PUMP N/A ❑ Submersible Turbine ❑ Other HP Pump Set ft Standing Water Le* ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the followm items: "jS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing � potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Do e , AQUIN Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed w'MbTRONMENTAL COUNTY MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 HEALTH DEPARiIAENT DEPARTMENT USE ONLY e6/� o� Application Accepted By � Date �� a Area -/% Employee ID# A-' Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boning Ins etion B Date Constructed Well Det COMMENTSre11�� Ufi r'- Qilew- t lsl9 U t'Pif 6Y Gerby'-NdoatFr- IS 9011aV 1`� PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B sh Remitted Service Re u st#. 37a o *d 4 3,-; W. /0 EHD043-06 04/07/2022 ' VS Z Z f ^ {d Wel I/Pump Permit 64 Q Y OV