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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1665 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)465-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 315 E 11 th Street CITY/ZIP Tracy, CA 95376 m <br /> CROSS STREET East Street APN 2.333701 O PARCEL SIZE 3br 0 LAND USE APPLICATION# <br /> OWNER NAME Tracy Unified School District PHONE 209-830-3200 y <br /> OWNER ADDRESS 187..9 W I nwell Avenue CITY/STATE/ZIP-Tram CA 95376 <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 . <br /> CONTRACTOR ADDRESS 1915 Commercial Street CITY/STATE/ZIP Escondido, CA 92029 <br /> SUBCONTRACTORICONSULTANT BSK Associates PHONE 916-853-9293 <br /> SUBCONTRACTORICONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CITY/STATE/ZIP Rancho Cordova CAp 95670 <br /> LICENSE X C-57 C-61 ❑D-09 G Other NUMBER 804318 EXPIRATION DATE 02/28�2022 <br /> BILLING PARTY: OWNER -:CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:-i General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private r 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 C Well Alteration/Modification -Other <br /> Monitoring Well(s) #of wells Soil Boring(s) n of bOen9s X Geotechnical 4 of bodngs <br /> Out-Of-Service Well r Out-Of-Service Well Renewal Cross-Connection Repair <br /> -New Pump ❑Pump Replacement =Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary .:.I Air Rotary X Auger L Cable Tool Push Point ci Other <br /> Proposed Well Depth 15 ft Excavation 6-8 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> _i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad _Steel -1 Plastic ❑Stainless Steel Other <br /> Grout Seal Depth 15 ft X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) -Other <br /> Grout Placement Method L Pumped X Free Fall C Other -Retardant/Accelerator name <br /> Installed By E Driller -Pump Contractor Other <br /> Concrete Pedestal_,Dimensions:Width ft Length ft Thick in :Christy Box Stove Pipe <br /> PUMP Submersible Turbine _ Other HP Pump Set ft 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 /> NIMUI144 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 7.J�"(^� TITLE Owner DATE 7/27/2020 <br /> F YMEN <br /> C 3 p ?AZO <br /> 4 QUl <br /> ` DEP 1V�UN� <br /> QRTMENl <br /> DEPARTMENT USE ONLY ✓ <br /> Application Accepted By /O'Z� Date Area S r C Employee ID# S/C <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date LI WAIVER Received <br /> Soil Boring Inspection By AW UJIllud, <br /> f Date Constructed Well Depth ft <br /> COMMENTS T- <br /> PE SC Received e1CRe—cR#jp Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted e vice Request# <br /> �a l� orf: <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />