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f • f <br />♦ T <br />I WELL/PUMP PERMIT <br />SAN.JOA0,utN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS 1014 S. Airport Way <br />CROSS STREET Wawona Street <br />OWNER NAME Robinson Oil Corporation <br />OWNER ADDRESS 955 Martin Avenue <br />CONTRACTOR ConeTec <br />CONTRACTOR ADDRESS 820 Aladdin'Avenue <br />SUBCONTRACTOR Korbmacher Engineering <br />SUBCONTRACTOR ADDRESS 480 Preston Court, Suite B <br />CALL (209) 953-7697 FOR INSPECTIONS EXPIKE5 9 YEAR FROM UATE <br />APN 222-19-051 <br />LICENSE 0 C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/ZIP Manteca, CA 95337 <br />PARCEL SIZE dJOal LAND USE APPLICATION # <br />PHONE <br />CITY/STATEIZIP Santa Clara, CA 95050 <br />PHONE 510-357-3677 <br />CITY/STATE/ZIP San Leandro, CA 94577 <br />PHONE 925-454-9033 <br />CITY/STATE/ZIP Livermore, CA 94551 <br />NUMBER 1049248 EXPIRATION DATEJan 31, 2023 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring XI 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 />pit <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings )❑ Geotechnical 1 <br /># of borings A� / <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />s <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION N/A <br />`Sq <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point p Other CPT <br />A/ <br />Proposed Well Depth 50' ft Excavation 1.5" in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size /Y If✓ <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Tit/DEpq� <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel <br />❑ Other <br />Grout Seal Depth Full Depth ft 11:3 Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement <br />sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped Q 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 2001 radius of proposed well. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY ,�y� <br />Application Accepted By 6� 1✓ Date 6 Are `* / "414(44'+ Employee ID#� <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Ins ection By Date b Sv'� �Constructed Well De th ft <br />COMMENTS /f t-yV11e _ �J` e"' : ' ;! k - 1' <br />to <br />m <br />m <br />g <br />0 <br />fn <br />PE <br />Codes <br />Sc Received Check#/ <br />Info Bv Cash <br />Amount ate Permitl Invoice # Well ID# <br />Remitted Service Re ues # <br />3-7a <br />190 <br />s <br />EHDO43-06 04/07/2022 Page I of 2 Well / Pump Permit <br />