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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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> JOB ADDRESS 1280 Dove Drive CITYIZIP Tracy, CA 95376 6DD <br /> CROSS STREET Raven Court APN 24204023 PARCEL SIZELAND USE APPLICATION# A <br /> m <br /> OWNER NAME Tracy Unified School District PHONE 209-830-3200 y <br /> OWNER ADDRESS 1875 W Lowell Avenue CITY/STATE/ZiP Tracy, CA 95376 <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street CITY/sTATE/ZIP Escondido,CA 92029 <br /> SUBCONTRACTOR/CONSULTANT BSK Associates PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CITYISTATE/ZIP Rancho Cordova CA 95670 <br /> LICENSE X C-57 ❑C-61 ❑D-09 C Other NUMBER 804318 EXPIRATION DATE 02/28/2022 <br /> BILLING PARTY: L OWNER IL CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391) _I Dibromochloropropane(4392) I Arsenic(4393) <br /> INTENDED Use Domestic/Private C Irrigation/Agricultural L Industrial L 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 C Replacement Well F Well Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells - Soil Boring(s) #of borings X Geotechnical�_#of borings <br /> Out-Of-Service Well L Out-Of-Service Well Renewal L� Cross-Connection Repair <br /> C New Pump ❑Pump Replacement -Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary X Auger D Cable Tool -_ Push Point C Other <br /> Proposed Well Depth 15 ft Excavation 6-8 in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> Li Conductor Casing in diameter I Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel C Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 15 ft X Neat Cement(94 Ib bag/5-10 gal water) C Sand Cement sack mixrl gal water <br /> I Bentonite(20%solids) ❑Other <br /> Grout Placement Method - Pumped X Free Fall D Other C Retardant/Accelerator name <br /> rMOIAL Installed By C Driller C Pump Contractor C Other <br /> L Concrete Pedestal LiDimensions:Width it Length ft Thick in L Christy Box L Stove Pipe <br /> PUMP j 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 <br /> � <br /> UM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED�CIiGaJ% `-� TITLE Owner DATE 7/27/2020 <br /> YM�NT <br /> 02020 <br /> co <br /> �NrY <br /> R T I KENT <br /> > DEPARTMENT USE ONLY <br /> pp p y ,: !�� � j/Cf Employee ID# <br /> Application Accepted 8 Date 7 � DaC+ Area <br /> Grout Inspection By Date ❑ SPECIA Well Permit <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info s Remitted Service Re est# <br /> so <br /> ;71T <br /> _ <br /> EHO 4306 6/1112019 WELL/PUMP PERMIT <br />