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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY EW MONMENTAL HEALTH DEPARTMENT 1968 EAST HAZELTON AvENua • STOCKTON CA 95205-6232 (209)196.3420 <br />ADDRESS 1021 Industrial Drive cmrrzw _Stockton. CA 95206 <br />ss STREET SAlroortWaY APN 177-280-140 —PARCEL Sla2 .98CL"oLinAPPLICATION0 <br />SER NAME Ingredion. Inc. Ryan- LLC PHONE <br />SER ADDRESS One PPG Place. Suite 2812810 CmISTATEIZIP Pittsburgh, PA 15222 <br />Exploration xploration Geoservices. Inc. PHONE (44) 28n-6829 <br />TRACTOR ADDRESS 1535 Industrial Avenue C"YISTATFIZIP San JOSE1 A_25112 <br />CONTRACTORICONaULTANT Cornerstone Earth Group PHONE (4$)_245-4600 <br />:ONTIIACTORICONSULTAWAOORM 1259 Oakmead Parkway CnYrSTATE ZIP Sunnyvale. CA 95050 <br />X C-57 tl C-61 ii D-09 : Other NuMaER 4842AA ExrouTKtNDATE <br />PARTY: (I OWN" CONTRACTOR XSuacaNTRACToRtCCNDIATANT <br />DOMESTIC WELL SAMPLING: I I General Mineral/Coliform Bacteria (4591) t I Dlbromochloropropane (4392)', 1 Arsenic (4393) <br />INTENDRn Usti ❑ Domestic/Private f InigationlAgricultural I I Industrial n Water Oustity Monitoring ! ! Soil Sem plin9fCharaclerization <br />11 Public Water System <br />11 afleronl from Oemar. Woter system Nemo CwULI Nome gPhme Number <br />TYPE OF WORK u New Wall I 1 Replacement Wel IWell Alterettott/Moditication Other <br />11 Monitoring Wel(s) 9 of wells X Soil 80fing(s) a O'b*— XG6010chnical _�s or boMes <br />11 Out-Of-Servico WW1 �' Out-OfSonAco Wel Renewal :. Cross -Connection Repair <br />I': New Pum !' Pump Replacement " Pump Re air "' Raise Well Casing <br />WELL CONSTRUCINTN <br />Drilling Method I! Mud Rotary : Air Rotary X Auger i Cable Tod C Push Point ' Other <br />Proposed Well Depth 45 Excavation 6 in diameter it Open Bottom ! ; Gravel Pad(/Gravel Size In diameter <br />U Conductor Casing In diameter I Conductor Casing Depth it <br />Well Casing Diamaler _ In Thickness/Gauge/ASTM Schad n Steel n Plastic I Slalnless Steel I1 Other <br />Grout Seal Depth it C3 Neat Cement (941b bag/5.10 gal wafer) 11 Sand Cement sack rNxf7 gal water <br />11 Benlontle (20% setidn' 0 Othar <br />Grout Placement Method i I Pumped Free Fag ,Y! OIher _- r -I Retardant / Acceteralor (name) <br />a a A Installed By ! Driller 0 Pump Contractor i Other <br />11 Concrete Pedestal �-Dlmenslons! Width 9 Length fl Thick In Christy Box Stove Pipe <br />1'J'2 C Submersible; Turbine :) Other HP Pump Sel It Standing Water Leve) rt <br />I HEREBY CERTIFYFRINANHCAE7S <br />T I PREPARED THIS APPLICATION AND THAT THE WORK HALL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ViDVR"E CALIFORNIA CONTRACTORS STATE LICENSE 130ARD AND THAT I AM IN COMPUANCE WITH ALL <br />ADVANCE NOTICE REQUIRED F INSPECTIONS - PLEASE CALL (209) <br />TrnE ` 'Aft %ot""M DATE 7 <br />DEPARTMENT USE ONLY <br />Application Accepted By — pato " R Area :>{J(✓ f'"Employee 100 <br />Grout Inspection By ��"� ��-� Date —" 1 I I SPECIAL Well Permit <br />Pump inspection By Date ' I I WAIVER Received <br />Sol Boring Inspection By Date 'Constructed Well Depth ft <br />COMMENTS /C' W1m r P .�O r� ►SSE 7 v c !, ^ , �. i :?�. {G1P <br />U) <br />a <br />RFq YMF <br />CEjV �T <br />oq 4?1 <br />Q� <br />C <br />D p4�� 4t <br />MFNT <br />PE <br />Codes <br />SC I Received Cheem <br />Info h <br />Amount <br />Remitted <br />Data Pormw invoice a Well IDA <br />Service R uest a <br />i <br />rxlE <br />I rt� ' L,l <br />EHD uas &11RD10 ��] � / J � �� ^ ��I `/ WELL RVI✓.P PE R/!Jr <br />