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s_ r WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 31°FL-STOCKTON CA 95202-(209)4694420 NON-REFUNDABLE PERMIT CALI, 209)953-7697 FOR INsrI:cIIONS EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS Calico rna Road CDvfzIP Galt- o4� s? Q6yy d CROSS STREET Woodson Road APry VL-5'— OS`C--7f PARCELSIZE a 7 KQx.25 OWNER NAME Galt Joint Unified School DistrictpR�NE(209} 745-3094 OWNER ADDRESS 417 C Street, Ste. B CrrvlSTArE1zIr Galt CA 95632 CONTRACTOR Earth Systems Pacific p PBDNE(805) 544-3276 CONTRACTOR ADDRES94378 Santa Fe Road ciTvisTATErz,PSan Luis Obispo, 93401 SUBCONTRACTOR PC Exploration PBONE-C916) 434-4200 SUBCONTRACTORADDRESS 3883 Cincinnati Ave. CrrvISTATE/ZIPRocklin' CA 95765 LICENSE i C-57 13C-61 0 D-09 ❑Other NUmuEkZjU556 EXPIRATION UATE CEOGRAPHICAL INFORMATION: Coordinates X Y Township Runge Section INTENDEI0 USE ❑DomesliclPrivale ❑IrrigationlAgricuhural ❑Industrial 0 Water Quality Monitoring }'Soil SamplinglCharaclerizalion Cl Public Wafer System lfdiffrmnl r—O.— atcr yv—N.— onmrr Namror une um r TYPE OF WORK ❑New Well ❑Replacement Well 13 Well Alteration/Modification D Test Hole ❑Other 0Monitorin Wells armhaTufwdis '�(� —,t—rlwrinp, rwmbcrarbo.in B OI Soil Borings) ❑Geotechnical p' D Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Weal Renewal Q New Pump ❑Pumn Replacement Q Ejm2 Repair ❑Cross-Connection Re it WELL CONSTRUCTION Drilling Method 0 Mud Rolary ❑Air Rotary 01Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 5-50 n Excavation $ in diameter D Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter I Conductor Casing Depth it Well Casing Diameter in ThicknesslGaugelASTM Sched ❑Steel d Plastic ❑Stainless Steel- ❑Other Grnul Seal Depth R 13 Neat Cement(94 lb bag/5-10 gal w ucr) 0 Sand Cement sack mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on Pile ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant!Accelerator(name) PEDESTAL Installed By ❑Driller D Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width Il Length n Thick in 1]Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set n Standing Water'Levei D WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter_in Total Depth ft Depth to Water ft ❑Casing be Perforated n11 to �J � � _J Scaling Material D Neat Cement(94 fb bag/5-10 gal water) ❑Sand Cement ,rack mix/7 gal water ❑Bentonite Pellets J q 47u a L-�-� Bentonite(20%solids) ❑Manufacturer Spec%solids %n Name ❑Spe Son File d Specs Submitted - CSI Placement Method ❑Pumped ❑Free Fall ❑Other �-°�t-'Ty7�+�.5 1 !w—r`� 7L-C�L_ _� ❑Complete with Mushroom Cap 11 below rade ❑Complete to Existing Surlpce Pad 1 HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. 1 IN IU 4 HOUR. DV-ANCE NOTICE REQUIRED FOR I\°5{rEC:'tl0\ti SIGNED O .�'1TLE DATE-------------- T' ------------------- --------------- --------------- ------------------ - 04 rr- DEPARTMENT USE ONLY Application Accepted By G Date �� Q Area � Employee IDN Ob" Grout Inspection By Date I] SPECIAL Well Permll Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Dale Constructed Well Depth R COMMENTS PE SC Amount Chcc Rcccivtd Permit/ Codes Info Remitted ash B Date Service Re vest# Invoice# Well ID# x{3.7 15,0 :z3c r-x) Z D 9S EHD 43-n2-006 enolzan3 Masicr Wmer WHI P—iw.