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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 350 E Mt. Diablo Avenue CITY/ZIP Tracy, CA 95376 <br /> CROSS STREET Shakespeare Court APIN 23511018 PARCEL SIZE .'r LAND USE APPLICATION# <br /> OWNER NAME Tracy Unified School District PHONE 209-830-3200 y <br /> OWNER ADDRESS 1..875 W I dwell Avenue CITY/STATE/ZIP Tracy, CA 95376 <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street crrylsTATE21P Escondido, CA 92029 <br /> SUBCONTRACTOR/CONSULTANT BSK AssociatesPHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CITY/STATErzIP Rancho Cordova, CAp 95670 <br /> IR <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 804318 EXPATION DATE 02/20/2022 <br /> BILLING PARTY: _OWNER _:CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392),D Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural F Industrial C Water Quality Monitoring X Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well 7 Replacement Well C Well Alteration/Modification D Other <br /> Monitoring Well(s) #of wells Soil Bodng(s) #of borings X Geotechnical�_ of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum G Pump Replacement 3 Pump Repair G Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary D Air Rotary %Auger D Cable Tool D Push Point F' Other <br /> Proposed Well Depth 15 ft Excavation 6-8 in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad D Steel Plastic 7 Stainless Steel D Other <br /> Grout Seal Depth 15 ft X Neat Cement(94 Ib ba9/5-10 gal water) Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method _ Pumped X Free Fall ,.Other Retardant/Accelerator name <br /> Installed By Driller i Pump Contractor :j Other <br /> ❑Concrete Pedestal :Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible_Turbine _ Other HP Pump Set ft Standintl 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 /> MINIMUyM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED�. d""l TITLE Owner DATE 7/23/2020 <br /> MFNr <br /> o ?0?0 <br /> zA <br /> F t/ Y <br /> 4 <br /> DEPARTMENT USE ONLY I� <br /> Application Accepted By 1' ` L� Date 7 C�O� Area S Ti4G Employee ID# �k' <br /> Grout Inspection By Date SPECT Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection ByX � Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Ch Amount Permit/ Invoice# Well ID# <br /> Codes Info Pate,RemittedService Re uest# <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />