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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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1760 W Kavanagh Avenue ctrymp Tracy. CA 95376 m <br /> D <br /> CROSS STREET Camelia Drive APN 21407002 PARCEL SIZELAND USE APPLICATION# z <br /> m <br /> OWNER NAME Tracy Unified School District PHONE 209-830-3200 <br /> OWNER ADDRESS 1 R75 W I OV1/ell Avaniip CITY/BTATE21P Tracy, CA 95376 <br /> CONTRACTOR Baia 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/STATE2IP Rancho Cordova, CA 95670 <br /> LICENSE X C-57 C-61 D-09 E,Other NUMBER 804318 EXPIRATION DATE 02/28/2022 <br /> BILLING PARTY: OWNER U CONTRACTOR X SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE F�Domestic/Private 'Irrigation/Agricultural r 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 r Well Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells Soil Boring(s) aofborings X Geotechnical of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal r Cross-Connection Repair <br /> i I New Pum G Pump Replacement 7 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary Air Rotary X Auger ❑Cable Tool n Push Point I i Other <br /> Proposed Well Depth 15 ft Excavation 6-8 in diameter r Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> 1 Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad r'Steel I Plastic ❑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 r_ Pumped X Free Fall Other r Retardant/Accelerator name <br /> Installed By Driller - Pump Contractor - Other <br /> Concrete Pedestal _Dimensions:Width ft Length ft Thick in a Christy Box a Stove Pipe <br /> PUMP _Submersible Turbine _ Other HP Pump Set It Standing 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 /> ►/MINIMUM <br /> 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> I� <br /> SIGNED A/L�..JTITLE Owner DATE 7/27/2020 <br /> li�A yMF <br /> CFj <br /> 3 ?020 <br /> C <br /> OU <br /> pARr Ei�Ty <br /> /DEPARTMENT USE N L Y /. <br /> Application Accepted By — Data 7 a O� Area s �7 Employee ID# S _ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By DateWAIVER Received <br /> Soil Boring Inspection By 00ann ss r ✓�. Date !Z Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Receivedheck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Re oast# <br /> EHD43-M 6/11/2019 WELLIPUMPPERMIT <br />