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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 � Golden Valley Parkway_ Lathro_ _CA 9533_0 4 -------------------------- -- -- -- ------ CITY/ZIP------Lathrop, W CROSS STREET River Islands PkwyAPN 192-04-055 PARCEL SIZE 6 .4 a&ND USE APPLICATION# v OWNER NAME Saybrook CLS P, LLC PHONE 310-266-4193 y OWNERADDRESS 303 Twin Dolphin Drive CITY/STATE/Zip-Redwood Shores, CA 9406 CONTRACTOR ENGEO I nC. PHONE (925) 321-5836 -------------------------------------------------------- --------------------- CONTRACTOR ADDRESS 17278 Golden Valley Parkway CITY/STATE/ZIP Lathrop, CA 95330 SUBCONTRACTOR West Coast Exploration PHONE (209) 985-7541 SUBCONTRACTOR ADDRESS PO Box 13 3 CITY/STATE/ZIP E s c a l on, CA, 95320______ LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 8 7 0 7 61 __ EXPIRATION DATE 1/31/24 DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)C Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ 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 ❑ Monitoring Well(s)—__—__ #of wells ❑ Soil Boring(s) #of borings g Geotechnical 4 _----#of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary 9 Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth__l0_3 5_ft Excavation _4—__— in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size------- inter ❑ Conductor Casing____ --in diameter / Conductor Casing Depth ft ppYM94 Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other FZECENFED - Grout Seal Depth 10-3-5--ft X Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement___—----__-----sact� J x,47 9VI NO ❑ Bentonite(20%solids) ❑ Other � "1 Grout Placement Method ❑ Pumped ❑ Free Fall N Other Tremie ❑ Retardant/Accelerator(name)__—__—___— couN31 F Nt PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick �in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. NIINLNII Al 24 HOUR AD%'ANCL NO ICE REQIIIREll FOR INSPEC I IONS-PLEASE('ALL(209)953-7697 --//DEPARTMENT USE ONLY Application Accepted By Z� L.—_—_ 10L?X ` _ � —_ Employee ___ Date_ _ _ Area__— , Em to ee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By _ Date------------- ❑ WAIVER Received Soil Boring Inspection By . Date_1T Constructed Well Depth ft COMMENTS-------------- — ------------- -------------------------------------------------- PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# -7v� PIS4LAJp00q3qqS EBD043-06 04/07/2022 Page 1 of 2 Well/Pump Permit