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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.siaov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1700_N. _Ch_ri sma_n Road CITYmP Tracy, CA m <br /> CROSS STREETGrant Line RoaC�I- 25002093 75.14 acres c <br /> N PARCEL SD!E LAND USE APPLICATION# D <br /> A <br /> OWNER NAME Prologis - Matthew Sims PHONE rNil <br /> OWNER ADDRESS 815 International Parkway CITYISTATEIZIP Tracy, CA 95377 <br /> CONTRACTOR Geo-Ex Subsurface Exploration PHONE 916-799-8198 <br /> CONTRACTOR ADDRESS 1510 Madera Drive QTY/STATE/ZIP Dixon, CA 95620 <br /> SUBCONTRACTOR/CONSULTANT ENGEO Incorporated PHONE 916-337-7281 <br /> SUBCONTRACTOR/CONSULTANTADDRESs17278 Golden Valley Pkwy CITY/STATEJZIP Lathrop, CA 95330 <br /> LICENSE LNC-57 ❑C-61 r]D-09 ❑Other NUMBER 954267 E%PIRATION DATE <br /> BILLING PARTY: ❑OWNER 0 CONTRACTOR LXSUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:U General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)G Arsenic(4393) <br /> NUE ❑Domestic/Private n Irrigation/Agricultural ❑Industrial 0 Water Quality Monitoring 0 Soil Sampling/Charactenzation <br /> D Public Water System <br /> If different from Owner Water System Name Contact Name or Phme Number <br /> TYPE OF WORN 0 New Well ❑Replacement Well D Well Alteration/Modification Cl Other <br /> D Monitoring Well(s) #of wells Woil Bonng(s) 8 #of borings ❑Geotechnical #of borings <br /> D Out-0f-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> Ll New Pump D Pump Replacement ❑Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method QCMUd Rotary ❑Air Rotary 0 Auger 0 Cable Tool 0 Push Point U Other <br /> Proposed Well Depth 80 ft Excavation 6 in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel D Plastic n Stainless Steel 0 Other <br /> Grout Seal Depth 80 ft Meat Cement(94 Ib bag(5-10 gal water) D Sand Cement sack mixf7 gal water <br /> D Bentonite(20%solids) G Other <br /> Grout Placement Method F1 Pumped ❑Free Fall [NOther tremmie ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal 0Dimensions.Width ft Length ft Thick in 0 Christy Box G Stove Pipe <br /> PUMP C Submersible❑Turbine D Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> .,....iri,IUfyl 48' ,ADVANCE NOTICE RE J 3 FOR.y;]S? C-1� OI�SY-PLEASE CALL(209)95' 7697'] <br /> SIGNED -J `'jVTITLE 1/Jf`L�—" DATE <br /> see attached site <br /> plan for proposed <br /> locations <br /> N7 <br /> Fp <br /> E VI O IH 0U rY <br /> Oki-1 1 J­L. ————# k <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Arear L y Employee ID# S/� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By_ ( ��� Date / 240 Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received C eek#/ Amount Date Permitt Invoice# Well ID# <br /> Codes Info h Remitted Service R uest# <br /> FHD43-06 6111f2019 <br /> WELL/PUMP PERMIT <br />