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r � <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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 751 W Lowell Avenue CITYIZIP Tracy, CA 95376 <br /> D <br /> CROSS STREET N Tracy Blvd APN 23216002 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME Tracy Unified School District PHONE 209-830-3200 y <br /> OWNER ADDRESS 1875 W Lowell Avenue CITYisTATE21P Tracy, CA 95376 <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 _ <br /> CONTRACTOR ADDRESS 1915 Commercial Street CITYISTATE21P Escondido, CA 92029 <br /> SUBCONTRACTOR/CONSULTANT BSK Associates .yy PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold CampDr.#160 CITY/STATE/ZIPRancho Cordova CA 95670 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 804318 ExPIRATION DATE 02/28/2022 <br /> BILLING PARTY: OWNER i_CONTRACTOR X SUBCONTRACTOR/CONSULTANT <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 New Well -Replacement Well i. Well Alteration/Modification G Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings X Geotechnical 2 of borings <br /> _Out-Of-Service Well L Out-Of-Service Well Renewal F Cross-Connection Repair <br /> i New Pump Pump Replacement J Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary Air Rotary X Auger J Cable Tool I1 Push Point D Other <br /> Proposed Well Depth 155 ft Excavation 6-8 in diameter -I Open Bottom D Gravel Pack/Gravel Size in diameter <br /> I-j Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ]Plastic 7 Stainless Steel ❑Other <br /> Grout Seal Depth 15 ft X Neat Cement(94 Ib bag/5-10 gal water) 7 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method - Pumped X Free Fall i Other a Retardant/Accelerator name <br /> IREUESTAL Installed By -Driller - Pump Contractor - Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible-Turbine _ Other HP Pump Set It Standinq Water Level ft <br /> " 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. 1 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 /> INII HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED "' "j TITLE Owner DATE 7/27/2020 <br /> E FNT <br /> CEO <br /> F0?0?0 <br /> TZc <br /> E T q��Ty <br /> MF^lT <br /> / _DEPARTMENT USE ONLY <br /> Application Accepted By � `� Date D O Area_` /+' Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Into as Remitted ervice Request# <br /> -43 l� S O <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />