Laserfiche WebLink
f � <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 PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> w <br /> Jos ADDRESS _ 535 Mabel Josephine Drive CITYrzIP Tracy. CA 95377 m <br /> a <br /> CROSS STREET Blackstone Drive APN 24007010 PARCEL SIZE 10-0/LAND USE APPLICATION# z <br /> m <br /> OWNER NAME _Tracy Unified School District PHONE 209-830-3200 y <br /> OWNER ADDRESS 1875 W Lowell Ayeni ip crrY/sTATErzIP Tram CA 95376 _ <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 _ <br /> CONTRACTOR ADDRESS 1915 Commercial Street cITY/sTATErzIP Escondido,CA 92029 <br /> SUBCONTRACTOR/CONSULTANT BSK Associates PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CITY/STATEMP Rancho Cordova, CA 95670 <br /> LICENSE X C-57 C-61 D-09 "Other NUMBER 804318 EXPIRATION DATE 02/28/2022 <br /> BILLING PARTY: _ OWNER _CONTRACTOR X SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)--,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 D New Well 7 Replacement Well c Well Alteration/Modification -Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings X Geotechnical 2 #or bonngs <br /> Out-Of-Service Well r Out-Of-Service Well Renewal Cross-Connection Repair <br /> -New Pump a Pump Replacement 7 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 7 Air Rotary X Auger '1 Cable Tool Push Point Other <br /> Proposed Well Depth 15 ft Excavation 6-8 in diameter -Open Bottom a Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel -Plastic ' Stainless Steel -:Other <br /> Grout Seal Depth 15 ft X Neat Cement(94 111 bag/5-10 gal wafer) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method L: Pumped X Free Fall Other Retardant/Accelerator name <br /> Installed By -1 Driller Pump Contractor 7 Other <br /> Concrete Pedestal-Dimensions:Width ft Length ft Thick in Christy Box .,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 /> NIMUM ,f�HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �.u�� / TITLE Owner DATE 7/27/2020 <br /> F yMFN <br /> 30 2420 <br /> QrJ/N <br /> oEPgR�°U/Vry <br /> NT <br /> DEPARTMENT USE ONLY ,J <br /> Application Accepted By _ Date 7 3V OD�0 Areas Uc Employee ID# Sk <br /> Grout Inspection By Date D SPECIAL Well Permit <br /> Pump Inspection By Date i I WAIVER Received <br /> Soil Boring Inspection By (A tlkxtd ate Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# WellID# <br /> Codes Into Remitted Service Re uest# <br /> 37d sU <br /> EHD43-06 611112019 WELL/PUMP PERMIT <br />