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s , <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 PERMITWWW.S OV.Of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS —JI70 N, Gct(kEr0160 I(:G1 ion CrrY/ZIP Tracy, CA 95376 <br /> CROSS STREET Parker Avenue APN 23314028 PARCEL SIZE,_LAND USE APPLICATION# <br /> OWNER NAME Tracy Unified School District PHONE 209-830-3200 y <br /> OWNER ADDRESS 1875 W Lowell Avenue CITYISTATEmp Tracy, CA 95376 <br /> CONTRACTOR Baia Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street cITY/sTATEmP Escondido,CA 92029 <br /> SUBCONTRACTOR/CONSULTANT BSK AssociatesPHONE 916-853-9293 <br /> ��yy <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr.Yf 160 CITY/STATE/ZIP Rancho Cordova, CAp 95670 <br /> LICENSE X C-57 I C-61 C D-09 11Other NUMBER 804318 EXPIRATION DATE 02/28�2022 <br /> BILLING PARTY: OWNER U CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)Lj Arsenic(4393) <br /> INTENDED USE Domestic/Private _ Irrigation/Agricultural - Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK E New Well 7 Replacement Well C Well Alteration/Modification C Other <br /> Monitoring Well(s) #of wells -Soil Boring(s) #of borings X Geotechnical�_#of bodngs <br /> Out-Of-Service Well i-Out-Of-Service Well Renewal C Cross-Connection Repair <br /> New Pump ❑Pump Replacement =Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 1 Mud Rotary ❑Air Rotary X Auger L Cable Tool j Push Point Other <br /> Proposed Well Depth 15 ft Excavation 6-8 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 Schad '7 Steel Plastic i-Stainless Steel G Other <br /> Grout Seal Depth 15 ft X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method i_ Pumped X Free Fall : Other (i Retardant/Accelerator name <br /> Installed By f I Driller G Pump Contractor Other <br /> Concrete Pedestal_iDimensions:Width ft Length ft Thick in li Christy Box Lj Stove Pipe <br /> PUMP Submersible_Turbine Other HP Pump Set It Standing Water Level It <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 /> •Myr/��'IMUUMJ4fjQ�',HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 'r-- "' "7- TITLE Owner DATE 7/27/2020 <br /> pq YM <br /> EO <br /> a Q 30 20 <br /> / V/N <br /> :# NT <br /> f' DEPARTMENT <br /> YS9 ONLY <br /> Application Accepted By G i�Z1Z_ Date 7 ?O X w Area [Oct Employee ID# <br /> Grout Inspection By Date ❑ PECIA Well Permit <br /> Pump Inspection By Date C WAIVER Received <br /> Soil Boring Inspection By 142AA, Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hac Amount Date Permit/ Invoice# Well ID# <br /> Codes Into Remitted S 'vi R u st# <br /> EHD43-06 6111/2019 WELL/PUMP PERMIT <br />