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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /G.104 Golden Valley Parkway __-- Lathrop, CA 95330 — m <br /> CITY/ZIP— P — <br /> River IslandsPk 192-04-055 6 .4 ac g <br /> CROSS STREET_ WYAPN PARCEL SIZE LAND USE APPLICATION# o <br /> Saybrook CLSP LLC 310-266-4193 <br /> OWNER NAME PHONE w <br /> OWNER ADDRESS 303 Twin Dolphin Drive — _—_ CITY/STATE/ZIP Redwood Shores, CA 9406 <br /> CONTRACTOR ENGEO Inc. __--- _ PHONE (925) 321-5836 <br /> 17278 Golden Valle Parkwa Lathrop, CA 95330 <br /> CONTRACTOR ADDRESS --_ y __�_ CITY/STATE21P_—_— _ <br /> SUBCONTRACTOR West Coast Exploration PHONE (209) 985-7541 <br /> SUBCONTRACTOR ADDRESS PO Box 133 __—_— CITY/STATE/ZIP Escalon, CA, 95320 <br /> LICENSE xl C-57 0 C-61 ❑ D-09 ❑ Other__-- NUMBER 8 7 0 7 61 ExPIRATION DATE 1/31/2 4 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)E Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private ❑ Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System_ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) #of wells 0 Soil Boring(s)____ #of bon rigs 76 Geotechnical 4 —#of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 0 New Pump ❑ Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 9 Auger ❑ Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth 10-35 ft Excavation _4_ in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size-___—_in ter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth _ft ppYM�� <br /> Well Casing Diameter— in Thickness/Gauge/ASTM Sched— ❑ Steel 0 Plastic 0 Stainless Steel ❑ OtherRECE�VED <br /> Grout Seal Depth-10-35 ft &Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement___—_---_saQc��I gtI <br /> 0 Bentonite(20%solids) ❑ Other 1 JJ <br /> Grout Placement Method ❑ Pumped ❑ Free Fall :6 Other Tremi e ❑ Retardant/Accelerator(name) �,cOUNI'r <br /> 1R -N <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> lin ❑ Christy Box 0 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 /> MININIUNI 24 HOUR AD%'ANCE NOTICE REQUIRED FOR 1NSPF.CI IONS-PLEAS}:CALL(209)953-7697 <br /> /DEPARTMENT USENL //jj Y r ,� <br /> Application Accepted By /�-L�L _— Date a Area 3 % Employee ID#_r� <br /> Grout Inspection ByDate _ ❑ SPECIAL Well Permit <br /> Pump Inspection By--__—_---__—_ Date_---_--___ ❑ WAIVER Received <br /> Soil Boring Inspection By--__-- — Date_--- _ Constructed Well Depth---_—__—_—_ft <br /> COMMENTS--- -- ----- -------------------- --------------- <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info .-By 4 Cash $�R;Amlfttted Service Request# <br /> s� l �s 22Wp00q3qq3 <br /> 1HD043-06 04/072022 Pap 1 of 2 Well/Pump Pama <br />