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r } <br /> WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZILToN AVENUE-STOCKTON CA 95205-6232(209)468.3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ohd EXPIRES I YEAR FROM DATE ISSUED <br /> Joe AODREss _1_750 W Kavanagh Avenue _ cTTY/a► Tracy., CA 9537 _—... <br /> CROSS STREET C;amella Drive APS 21407002 PARCEL SIZE ( LAND USE APPL)CATION e <br /> OWNER NAME Tracy Unified School District -_-__ PHONE 209-830-3200 <br /> OWNER ADDRESS 1875 W Lowell Avenue Cri-Y/STATvals Tracy, CA 95376 <br /> CONTRACTOR Middle Earth Geo Testing Inc. PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 N Lemon Street cff f5,ATvaP Orange, CA 92767 <br /> SUSCONTRACTOR/CONSULTANT t3SK Associat-C PHONE 916-853-9293 <br /> SuecoNTRACTORICONSULTANTADDRESS 3140 Gold Camp Dr.#160 CITYISTATE/ZlPgamho Cordova, CA 95670 <br /> LICENSE X C-57 C-61 D4)9 Other—_ NumaER 899451 Ex PtaAnoN DATE 06/30/2021 <br /> BILLING PARTY; OWNER CONTRACTOR },SUBCONTRACTOR/CONSULTANT <br /> Domestic WELL SAMPLING: General Mineral/Cdlforrn Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENOfO USE DnmesllGPriva!n Imgabon/Agricultural Industrial Water Ouaety Monitoring K Soil SamplinglCharacterizatlOn <br /> Pubhc Water System <br /> n <br /> 40—1,nein Owner W alar sy%l .N_ CereeO Nair a Ph—Number <br /> TYPE OF WORK New Well Replacement Well Well AReratiomModlicabon Other <br /> Monitoring We4(sl v at weds Sal Bonng(S) #&ti.K'' X Geoleehnlpi_ eteo"'a <br /> Out-Of.Sorvice Well Out-OI-Service Wei Renewal Cross-Connoction Repair <br /> New Pump Pump ReVacemert Pump Repair Raise Well Casing <br /> WELL CONSTRUCT" <br /> Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Oaptn 50 It Excavation 1.5 in diameter Open Bottom Gravel Pack Gravol SLze In diameter <br /> Conductor Casing in diameter I Conductor Casing Deptn R <br /> Well Casing Diameter_ in ThicknesslGauge/ASTM Schad Steel Plastic Stainless Sleet Otrer <br /> Grout Seal Depth 50 R X Neat Cement(94 lb DSW'S-10 gal water) Sand Cement sack ry":.7 cal water <br /> E! ,,,I n to k20%solids) Other <br /> Grout Placement Method Pumped Free Fail X Other CPT rodS/tfemmie Retardant/Accelerator iname) <br /> PEDESTAL Installed By Dollar Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width It Length h Thick 'n Christy Box Stove Pipe <br /> IJ.. Submersible Turbine Other HP Pump Set R Standing Water Level R <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COON Y ORDINA ES. STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY RE0UIREO LICENSE IS <br /> CURRENT AND WI THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL <br /> WORKERS COMP 5 TI WS <br /> MINIM DVANC iGE REQUIRED F SPEC N -P SE CALL y953-7697 <br /> SIGNED TITLE GATE -/--;1-I(J'2ta <br /> 11 LL, <br /> qc MINT <br /> F/AFD <br /> 3 ?420 <br /> zr U/N CCU <br /> FV/W tv A NT, <br /> r <br /> A R T MEN7- <br /> DEPARTMENT USE NLY <br /> Apphcalion Accepted By `— ' Date d Area 5 Employee IDN <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date� WAIVER Received <br /> Sod Boring Inspection Sy Data 1 Constructed Well Depth_ ft <br /> COMMENTS <br /> PE Sc Received C Amarrt PenTdV _T-- <br /> Cod" Iib ReedlNd DaN Service Request a Invoice/ j Well 10! <br /> �a s� <br /> EtiD+le! &117019 WELL'U/IPPitWiT <br />