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WELUPUMP PERMIT <br /> SAN JOAOu1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT lea EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468.1420 <br /> NON-REFUNDABLE PERMIT www.algov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 19511 S Austin Road cnY21P Manteca/95336 m <br /> CROSS STREET Graves Road -- T q kik 228-050-020-000 PARCEL SME 23 Ac LAW USE APPLICATION a <br /> OWNER NAME Piai Partnership c/o Elaine Scadden PHONE <br /> OWNER ADDRESS 1685 MCBAIN AVE crTY/STATE/ZIP SAN JOSE/CA 195125 <br /> CONTRACTOR Cuesta Geo,Inc. PHONE (925)872-1248 <br /> CONTRACTOR ADDRESS 2709 Kapalua Court CnY/STATEQIP Fairfield/CA/94534 <br /> SUBCONTRACTOR/CONSULTANT Cornerstone Earth Group PHONE (408)2454600 <br /> SuncowrRACTOR/CONaULTANT ADDRESS 1259 Oakmead Parkway Cm/STATEmP Sunnyvale/CA/94085 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 1043431 EXPIRATION DATE 8/31t2022 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DoMEsTic WELL SAMPUNO: :General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE I DomesliclPrlvate _Irrigation/Agricultural - Industrial -- Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> H dtrerent from Own_ Water System Name Conud Nam w Phone Number <br /> TYPE OF WORK New Well - Replacement Well - Well Alteration/Modification Other <br /> Monitoring Well(s) M of wells Soil Bonnq(a) MOI bonne. X Geotechnical 3 e of bwnps <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> _.New Pum =Pump Replacement .Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION Hollow Stem <br /> Drilling Method Mud Rotary Air Rotary X Auger Cable Tool .: Push Point Other <br /> Proposed Wall Depth 25 t0 40 R Excavation 6.5 in diameter Open Bottom Gravel PaddGravel Size it diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Schad -Steel Plastic - Stainless Steel Other <br /> Grout Seal Depth R X Neat Cement(941b bayS10 gal water) Sand Cement sack mhd7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall X Other Tremle Grout Retardant I Accelerator(name) <br /> PEDESTAL Installed By _Driller _Pump Contractor Other <br /> Concrete Pedestal -Dimanslons:Width R Length R Thick in Christy Box Stove Pipe <br /> MP Submersible-.Turbine Other HP Pump Set R Standing Water Laval R <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 Digitally signed by Chns Kneq TITLE DATE <br /> ri r.402112.13 C4:2*8 <br /> 1001 <br /> Ec MEN <br /> QED <br /> C �6 2021 <br /> V/N <br /> FNT <br /> I t H -1 __# - - <br /> DEPARTMENT USE ONLY <br /> Application Accepted BY L�— Date /Z ISE �) Area Employee IDM C7 <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ChecldlV Amount Dela Pennfl/ Invoke• Wall IDS <br /> Codas Info oak Cnb emitted ervice Requesto <br /> 7 pgo <br /> EHD I3O0 411/2019 �n r � /�✓����7 / � WELL.PUMP PERMR <br />