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f <br /> 7Y t <br /> 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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 2077 W Yosemite Avenue CITYCITY/ZIPManteca 95337 M)m <br /> CROSS STREET S Airport Way APN 200-140-130-000 PARCEL SIZE 0.757 ac LAND USE APPLICATION# o <br /> OWNER NAME ) II ak j L pr) Alt,V PHONE m <br /> OWNER ADDRESS 8537 Amares Circle CITYISTATE/ZIP Elk Grove,CA 95757 <br /> CONTRACTOR Cuesta Geo Inc PHONE (925)337-9567 <br /> CONTRACTOR ADDRESS 2709 Kapalua Ct CITY/STATE/ZIP Fairfield,CA 94534 <br /> SUBCONTRACTO NSULTANT OCornerstone Earth Group PHONE (408)245-4600 <br /> 1259 Oakmead Parkway Sunnyvale,CA 94085 <br /> SUBCONTRACTOR/ NSULTANT DRESS CITY/$TATE/ZIP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 1043431 EXPIRATION DATE 08/31/2022 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/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 different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells XSoil Boring(s) #of borings X Geotechnical 2 #of borings <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 X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 20 to 30 It Excavation 6.5 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 20-30 ft x Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixfl gal water <br /> Bentonite(20%solids) x Other boring backfilled with grout per county guidelines <br /> Grout Placement Method Pumped x Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length It 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 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) <br /> Tn953-7697 <br /> SIGNED <br /> SIGNED Digitally signed byChris Krieg TITLE DrZTsdpnt DATE 6130121 <br /> eme iI=1 1.n , <br /> = S <br /> - E yMF <br /> See Attached Map 0 J 2021 <br /> QVlN <br /> Fpq��oIVTy <br /> NT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Z� Date 7 7dJ <br /> Area Employee ID#A& <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring In e!ction�B//�� > Date "t Constructed Welt De h ft <br /> COfy1MENTS_ t CXP� CXP('TDT 3� �+� OY ['Yap.%Yr N1 o BY is eyu c1J",I, � rv�q /Iv <br /> IF L <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request III <br /> Invoice# Well ID# <br /> 4 7a 0 <br /> on <br /> EHD43-06 6/11/2019 04 ''_-t <br /> 4 7659765— WELL/PUMP PERMIT -� <br />