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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUI I-KEFUNDABLE I'ERMIT I:ALL (LUU) U0.5-/t)UI FOR INSPECTIONS tAtjIKtb l YEAR FROM UATE ISSUED <br />JOB ADDRESS 3030 Byron Road CITY/ZIP Tracy, 95377 <br />CROSS STREET Lankershire Drive APN 238-070-10 PARCEL SIZE I, 07 LAND USE APPLICATION # <br />OWNER NAME Country Builders Construction, Inc. PHONE <br />OWNER ADDRESS 5915 Graham Court CITY/STATE/ZIP Livermore, California 94550 <br />CONTRACTOR Korbmacher Engineering <br />CONTRACTOR ADDRESS 480 Preston Court, Suite B <br />SUBCONTRACTOR ConeTec <br />SUBCONTRACTOR ADDRESS 820 Aladdin Avenue <br />LICENSE N C-57 ❑ C-61 ❑ D-09 ❑ Other. <br />PHONE 925-454-9033 <br />CITY/STATE/ZIP Livermore, CA 94551 <br />PHONE 510-357-3677 <br />CITY/STATE/ZIP San Leandro, CA 94577 <br />NUMBER 1049248 EXPIRATION DATE 1/31/23 <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) L Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring N 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings N Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />3 # of borings <br />PAYN/E <br />WELL CONSTRUCTION <br />Amount Permit/ <br />Remitted ate Service Request # Invoice # Well ID# <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point X1 Other CPT <br />Proposed Well Depth 50' ft Excavation 1.5" in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br />Size in eft <br />❑ Conductor Casing in diameter / Conductor Casing Depth ftA� <br />N J <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched El Steel ❑ Plastic ❑ Stainless Steel <br />❑ cjl�N �AQU/N <br />Grout Seal Depth Full Depth ft N Neat Cement (94 /b bag/5-10 gal water) 11 Sand Cement <br />_ s�nli tkq <br />❑ Bentonite (20% solids) ❑ Other <br />TM <br />Grout Placement Method ❑ Pumped N Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />3EDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By L' �� Date 7 a7 a Area f4t-I Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By /I%z/ISI Date ��s'��Z Constructed Well Depth ft <br />COMMENTS _ <br />m <br />m <br />g <br />0 <br />IN <br />IN <br />Cnm <br />�T <br />D <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ <br />Cash <br />Amount Permit/ <br />Remitted ate Service Request # Invoice # Well ID# <br />7 d <br />ERIX143-06 04/07/2022 ' 1 1'aee I of ? Well /Pump Permit <br />�l `f72.9a73� <br />