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WELL/PUMP PERMIT <br /> SAN JOAcum COVNTy ENv1RONMENTAL HEALTH DEPARTMENT 1868 EAST HA!ELTON AVENUE•STOCKTON CA 95205 6232(209)468.3420 <br /> NON-REFUNDABLE PERMIT Www.sjgov_orglehd _ EXPIRES 1 YEAR FROM DATE ISSUED la <br /> Joe ADoRESs 2421 W Lowell Avenue _ CtrylZiP_TLaCy_LA 95'77 <br /> CROSS STREET I aurelhrook Drive APN 23860030 PARCEL SIZE - LAND USE APPLICATION a <br /> OWNER NAME Tracy Unified School Dictrlct _ PHONE_-209-830-3200 <br /> OWNER ADDRESS . 1875W Lowell Avenue__ CIrYrSTATE/z1P Tracy,CA 95376 <br /> CONTRACTOR Middle Earth Geo Testinglnc_. PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 N Lemon Street CrTY/STATE/ZW Orange,CA 92767 <br /> SUSCONTRACTORICONSULTANT BSK CSOCiateS PHONE 916-853-9293 <br /> SUncONTRACTORICOhsULTANT ADDRESS 3140 Gold Camp Dr.#160 C TY;STATUDI'Rancho Cordova.CA 95670 <br /> LICENSE XC-57 C-bt 0.09 Ott'@f NUMBER 899451 _ ExPIRAniDATE 06/30/2021 <br /> &LUNG PARTY: OWNER CONTRACTOR X SUBCONTRACTORICONAR.TANT <br /> Do4lEsnc WELL SAMPLING: General MinerallColiform Bacteria(4391) DibromochlDropropent(4390 Amentc(4393) <br /> INTEN0E0 UsE DcrtlesbrJPnvate Imgatlnn!Agrlrullural Industrial Water Quality Monitorirlg X Soil SamplingtCharactertzatwn <br /> Public Water System <br /> S do~t"Orae• WMa Syst—Nr Contac Name dr Pndrte Nu t6er <br /> TYPE OF WORK New Wen Replacement Well Wen ARerabon,ModAication Other <br /> Monitoring Wells) a of wells Sal Bonngls) a`—N. :t Geotechnical _s"'c"r <br /> Oul-Ot-Servico Well Out-01-Service Well Renewal Croas-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary X Auger Cade Tool Push Pcmt Other <br /> Proposed Well Depth 50 it Excavation 1.5 in diameter Open Bottom Gravel PacluGravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth n <br /> Well Casing Diameter_in ThickressrGauge,ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 it X Neat Cement(94 rD Dag/5.10 gel ve3i Sand Cement Salt mlr7 gal water <br /> j Bentonite(20%Solids) Other <br /> Grout Placement Method Pumped Free Fail X Other CPT rods/tremn'lle Retardant I Accelerator(name) <br /> PEOlsTAI Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dinanelons:Width R Length R Thk* in Christy Box Stove Pipe <br /> [=L Subrnerside T...hine OIMr HP Pump Sol it Standing Water Level It <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO SATT N LAWS. <br /> AO CE NOTICE REQUIRED F INSPEC )ON y-SPL ASE CALL(209))953-17`697 <br /> / <br /> SIGNED TITLE '�7✓1 DATE -Z4-Z0 O <br /> RFq <br /> ✓ c, rl <br /> A 30 <br /> q RpN��H c�ZO <br /> DFpq� 4 rY <br /> r <br /> DEPARTMENT USE.ONLY L <br /> Application Accepted By `�� Date e��0 ' Area 7'f r'IL i Employee IDN <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Son Boring Inspection By Date 91. PA> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received C ArnottrN Data Permit/nInvoice s Wall IDs <br /> as <br /> CodIfo RaNbd Servs Ra oast s _ <br /> 742 m`1�- <br /> EHD�}ds art lath wEIL.PuuP PERfAT <br />