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I <br />WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PETJ 1„. _ CAL - 12D9) 95_3-7,697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />LJ'1 X 7'e� KXIrn <br />Joe ADDRESS SiLe N -175 -Southeast side of Mountain Nouse ?kWyCrTY1ZIP <br />Tracy, CA 5537” <br />22�� <br />u�`'ALAND <br />D <br />CROSS STREET -400- scut F.weac of W. Schulte RdAPN 209-110-51 PARCEL SIZE <br />USE APPLICATION <br />o <br />CJ <br />N <br />OWNER NAME Phillips 66 Pipeline LLC, Attn: Mr. Josh Hopkins ,PNolyE <br />(562) 290-1543 <br />OWNER ADDRESS 7551 Carmelo Avenue /9% La), DT CITYISTATE/ZIP <br />Imo. 41 � <br />Trac CA 95304 `.1 --t <br />CONTRACTOR American Construction and Supply, Inc. <br />PHONE (415) 927-2024 <br />CONTRACTOR ADDRESS 45 San Clemente Drive, Suite A-100 CITYISTATE/ZIP <br />Corte Madera, CA 94925 <br />SUBCONTRACTOR N/A __. <br />PHONE_ <br />SUBCONTRACTOR ADDRESS N/A CITYISTATE/ZIP <br />LICENSE X C-57 "C-61 D -C9 Other NUMBER 310599 EXPfRAT1ONDATE 03/31/2.019 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />WENDED USE I-; DomesticlPnvale ::: Irngahon/Agncultural .: Industrial ❑ Water Quality Monitoring Li Soil Sampling/Characterization <br />i Public Water System <br />If diflerent horn Owner. Waley System Name Contact Name or Phone Number <br />TYPE OF WORK :c New Well t, Replacement Well Well AlteratiordModihcatwn x: Other Cathodic Protection <br />Monitoring Wen(s)__ # of wells = Soil Boring(s) # of boats - Geotechnical # of bonngs <br />Out -Of -Service Well Out -Of -Service Well Renewal -, Cross -Connection Repair <br />New Pump U Pump Replacement L Pump Repair Raise Well Casing <br />Drilling Method N Mud Rotary G Air Rotary -' Auger O Cable Tool .- Push Point Other <br />xe, rte <br />Proposed Well Depth 355 it Excavation 10 in diameter Open Bottom X Co(3raval Pa'&Jame07SUW in diameter <br />r; Conductor Casing N/A In diameter ! Conductor Casing Depth ft <br />Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched 40 :_ Steel 29 Plastic _ Stainless Steel Other <br />Grout Seal Depth > 100 ft Neat Cement (94 111 bag/5-10 gal water) Z Sand Cement 10.3 SacK rmx17 gal water <br />_ Bentonite (20% solids) '.- Other <br />Grout Placement Method L Pumped - Free Fall V Other Trani e C Retardant / Accelerator (name) <br />PEDESTAL Installed By = Driller i i Pump Contractor Other <br />N/A - Concrete Pedestal UDimensions. Width h Length It Thick in - Christy Box - Stove Pipe <br />PUMP "1 /A _: Submersible:. Turbine Other HP Pump Set ft Standing Water Level 1t <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES,*TATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CUT AND ACTIVE WITH CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WOS COMPENSATIO S. <br />MINIMU DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIG]! Steve McKim TITLE Vice President DATE 01/19/2018 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />04— <br />DEPARTMENT USE O LY <br />Date r� <br />Date i <br />Date <br />Dale <br />c1; A %-& --1-7 <br />Area ` Employee ID# /i p�-n trG1 <br />I PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received <br />Codes Info 8 <br />Check#/ Amount Date Permit/ Invoice # Well ID# <br />Cash Remitted Service Re uesit <br />h <br />1 <br />EHO 43-06 8/01,16 WELL /PUMP PERMI7 <br />