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JOB ADDRESS cirazip Stockton/95205 2940 Loomis Rd <br />CITY/STATE/ZIP Hayward/CA/94544 OWNER ADDRESS 29225 Taylor Ave <br />ApN 179-100-06 CROSS STREET 99 Frontage Rd <br />Jatinder Singh OWNER NAME <br />CITY/STATE/ZIP Escalon/CA/95320 CONTRACTOR ADDRESS P•°• Box 133 <br />PHONE 209-543-1799 SUBCONTRACTOR/CONSULTANT CTE CAL, Inc <br />NUMBER 870761 EXPIRATION DATE 1/31/2022 LICENSE N C-57 E C-61 0 D-09 0 Other <br />BILLING PARTY: 0 OWNER O CONTRACTOR M SUBCONTRACTOR/CONSULTANT <br />PARCEL SIZE 2.03 Ames LAND USE APPLICATION # <br />PHONE 510-200-6491 <br />West Coast Exploration, Inc PHONE 209-985-7541 CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Ave STE 150 CITY/STATE/ZIP Modesto/CA/95356 <br />Tremie it in 0 Retardant / Accelerator (name) <br />ft Thick in 0 Christy Box LI Stove Pipe <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal E Dim ension& Width ft Length <br />ft 0 Submersible: Turbine 0 Other HP PUMP Pump Set ft Standing Water Level <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, 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ieeZTfrfrtZa 3.1.245e:Lt- TITLE Staff Geologist DATE 12/28/2020 <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary N Auger 0 Cable Tool E Push Point 0 Other <br />Proposed Well Depth 20 ft Excavation 4 in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br /> <br />E Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel ID Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ),..) ft N Neat Cement (94 lb bag/5-10 gal water) LI Sand Cement <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall N Other <br />sack mix/7 gal water <br />in diameter <br />A A <br />1NELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST NAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) LI Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring A. Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well <br />0 Monitoring Well(s) # of wells <br />El Out-Of-Service Well <br />0 New Pump 0 Pump Replacement <br />0 Well Alteration/Modification 0 Other <br /> <br />0 Soil Boring(s) *of borings 2 Geotechnical 4 of borings <br />0 Out-Of-Service Well Renewal E Cross-Connection Repair <br />0 Pump Repair E Raise Well Casing <br /> <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Date h-7/1,Vif ();(.) Area / 61 Employee ID# <br />Date 0 l Qut \-113A. 0 SPECIAL Well Permit <br />Date E WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />VIKA <br />,c0h ca <br />, Amount <br />Remitted Date Permit/ <br />Service ReguestL Invoice # Well ID# <br />93 1,2 iSD if, 0 S-S17 tcl /i.? 1(,2172 NNIYO 1-0 (:''_7 VI ) <br />MI :SMICICIV 311S ft <br />EH D 43-06 6/11/2019 WELL /PUMP PERMIT