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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1021 Industrial Drive Ctnr/ZIP Stockton CA 95206 m <br /> p 1 D <br /> CROSS STREETS Airport Way APN 177-280-120 PARCEL SIZE7.4 aC LAND USE APPLICATION# z <br /> N <br /> OWNER NAME Ingredion Inc PHONE <br /> OWNER ADDRESS 888 Zephyr Street CRY/STATE/ZIP Stockton CA 95206 <br /> CONTRACTOR Middle Earth Geotesting Inc PHONE (714)633-5025 <br /> CONTRACTOR ADDRESS 27649 Industrial BouleVai CITY/STATE/ZIP Hayward CA 94545 <br /> SUBCONTRACTOR/CONSULTANT Cornerstone Earth Group PHONE--( 8)245-4500 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1259 Oakmead Parkway Cm/STATE/ZIP Sunnyvale CA 95050 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 899451 EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR XSUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If Off—nl Irom 0-.r Comact Name or Pharle Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> o <br /> Monitoring Wells) #of wells XSoil Boring(s) a f bohngs XGeotechnical 2 #m b.-91 <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 X Other Cone Penetration Testing <br /> Proposed Well Depth 150 ft Excavation 2.5 in diameter Open Bottom Gravel PackiGravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter—in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft ! Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids% Other <br /> Grout Placement Method Pumped Free Fall Other " Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COLINT�OR CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND A WI THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERSCOMPEN N WS. <br /> NdiNIN1UM 4 ! TICE REQUIRED F PSSPr. ' Ns -♦U,PI-E SE CA.!!_f2fl9) 53 P,977 <br /> SIGNED TITLE ``"' DATE L <br /> RF <br /> cF�V oT <br /> Rq� ,1 �0 <br /> oA/AjR COLINry <br /> Nr <br /> DEPARTMENT U.SE ONLY <br /> Application Accepted By Date Area - Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date AA WAIVER Received <br /> Soil Boring Inspection By Date 3�(G���' Constructed Well Depth ft <br /> COMMENTS 1'c t,SFL' Far iw,rrF'Pf/fM1' Ili"' >� I <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted So ice Re u t# <br /> i� 1. <br /> WELL)PUMP PERMIT <br /> END 63-06 6-112019 <br />