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EMAILED <br /> i g 3 C M WELL/PUMP PERMIT <br /> SAN JOAQUIN 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 640 W Mossdale RD (See Attached) Ln <br /> CITY/zIP Tracy, CA, 95304 m <br /> CROSS STREETManthey RD APN 239-030-140 PARCEL SIZE LAND USE APPLICATION# o <br /> m <br /> OWNER NAME Mossdale Associates, LTD, a California General Partnership PHONE <br /> OWNER ADDRESS 800 W Mossdale CITY/STATE/ZIP Lathrop, CA 95330 <br /> CONTRACTOR ENGEO, Inc. PHONE 209-876-9239 <br /> CONTRACTOR ADDRESS 17278 Golden Valley Parkway CITYISTATE/ZIP Lathrop, CA, 95330 <br /> SUBCONTRACTOR Drill X Subsurface Corporation PHONE (707)365-7951 <br /> SUBCONTRACTOR ADDRESS 704 N Adams Street CITY/STATE/ZIP Dixon, CA 95620 <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 1117378 EXPIRATION DATE 3131/28 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE C Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring X Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well ❑ Replacement Well ❑ Well Alteration/Modification XI Other Ong Penetration Tests <br /> C Monitoring Well(s) #of wells D Soil Boring(s) #of borings ❑ Geotechnical u of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool D Push Point ❑ Other Pushing a CPT Cone <br /> Proposed Well Depth 7 0—9 0 ft Excavationl - 5—2" in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> E. Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel C Other <br /> Grout Seal Depth 90 ft X Neat Cement(94 lb bag/S-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall IN other T remie ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP C 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 23 HOUR ADVANCE:NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT U E ONLY <br /> /r�4s> z�/G cis <br /> Application Accepted By Date Area 3 9 Employee ID# a/ <br /> Grout Inspection By Date C SPECIAL Well Permit �t <br /> Pump Inspection By Date C WAIVER ReceivMYMENT <br /> Soil Boring Inspection By Date nstructed Well Depth Q�('_FIN/ED <br /> COMMENTS !�C GTrr 2- 6e&�z yey/re 1 i <br /> PE SC Received Check#/ Amount Date Permit/ Invoice" I�IJTY <br /> Codes Info B Cash C Remitted Service Request# %AN OAQWN <br /> 7Z / �a 28 L6 WP2601 E <br /> EIM043-06 Oi n7i)22 fie 1,"`2 Weil;F-V pt- <br />