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EMAIL IED <br /> \', � M WELL/PUMP PERMIT <br /> .SAN JOAQUIN Cr ENVI ONME TAL EALTH 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) clrnzlP Tracy, CA, 95304 m <br /> CROSS STREETManthey RD APN 239-030-140 PARCEL SIZE LAND USE APPLICATION# o <br /> X <br /> OWNER NAME Mossdale Associates, LTD, a California General Partnership PHONE U) <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 CITY/STATE/ZIP Lathrop, CA, 95330 <br /> SUBCONTRACTOR Drill X Subsurface Corporation PHONE (707)365-7951 <br /> SUBCONTRACTOR ADDRESS704 N Adams Street CITY/STATE/ZIP Dixon, CA 95620 <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 1117378 EXPIRATION DATE 3/31/28 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring iA 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 XI Other Cone Penetration Tests <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #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 ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Pushing a CPT Cone <br /> Proposed Well Depth 70-90 ft Excavation]- . 5—2" in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 90 ft X Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall IX Other T remi e ❑ 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 ❑ 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 U E ONLY <br /> Application Accepted By /11� Date Z��y Area 3�99 Employee ID# <br /> Grout Inspection By Date E SPECIAL Well Permit <br /> Pump Inspection By Date E WAIVER ReceivPAYMEN l <br /> Soil Boring Inspection By Date I FilConstructed Well Depth RFr-PIVED <br /> COMMENTS <br /> nllr, 2 R 9076 <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info BV ash Cc Remitted Date Service Request# Invoice IhAN OAQl1 NIMUNTY <br /> 7Z / 3oD 8 WP260� EPIVIKUNMENTAL <br /> EM043.06 04/07/2022 Page 1 of 2 Uploaded into c c e a ell/Pump Permit <br />