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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDASLE PERMIT I:ALL LU'J `Jb3-fb`J/ FOR INSPECTIONS LAVIlKtS 7 YEAR FROM UATE ISSUED <br />JOB ADDRESS k � -7 -1' Dominique Drive and Basque Drive <br />CITYILP Tracy, 95304 <br />CROSS STREET Basque Drive APN 25226001 & 25205024 PARCEL SIZE 5 aCre eatlkND USE APPLICATION # <br />OWNER NAME TVC HOLDCO LLC. <br />It <br />PHONE <br />OWNER ADDRESS 3208 Wycliffe Drive <br />CITYISTATE/LP Modesto, CA 95355 <br />CONTRACTOR California Push Technologies, Inc. <br />PHONE 510-357-3677 <br />CONTRACTOR ADDRESS 820 Aladdin Avenue <br />CITY/STATPJZIP San Leandro, CA 94577 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATEIZIP <br />LICENSE 9 C-57 ❑ C-61 D D-09 D Other NUMBER <br />884827 EXPIRATION DATE September 2018 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />WENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial D Water Quality Monitoring 9 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 D Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings IX Geotechnical 5 # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger D Cable Tool Ix Push Point ❑ Other <br />Proposed Well Depth 50 ft Excavation 3 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 D Stainless Steel D Other <br />Grout Seal Depth ft X Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack m1x17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped X Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller D Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width it Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP D SubmersibleD Turbine ❑ Other HP Pump Set It Standing Water Level ft <br />1 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED "1.�/td,./ TITLE �n. 5,& 44 FNw�h C(/ DATE 144/1 <br />ffdc, <br />IMtNI U t N <br />Application Accepted By Date 1 <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection B Date <br />COMMENTS— <br />2011 <br />COUN'T'S <br />Area � �D <br />❑ ell <br />Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />EHD 43-M 8101116 WELL/PUMP PERMIT <br />