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WELL/PUMP PERMIT <br /> SAN JOAQVIN COUNTI ENVIRONMENTAL HEALTH DEPAiiTYEN- 1868 EAST I/AZELTON AVENUE-STOCitTON CA95205-6232(209)468.3420 <br /> NON-REFUNDABLE PERMIT _ wwW.ajgOv or�ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS Carlton Way __ CITT,nP Tracy- CA 95376 5 <br /> CROSS STREET Madison Avenue APN 23216008 PARCEL S"0,2 LAND USE APPLICATION Z <br /> OWNER NAME Tracy Unified School District PHONE 209-83Q-a2QQ__ <br /> OWNER ADDRESS 1875 W Lowell Avenue CrrItSTATErb. Tram CA 95376 <br /> CONTRACTOR Middle Earth Geo Testing Inc. PHONE 714-633_5025 <br /> CONTRACTOR ADDRESS 954 N Lemon Street Crrr/STATEMP Orange, CA 92767 <br /> SUSCONTRAC TOP,CONSULTANT RSK Associates PHONE_((`911'6-^8`5'3-/9'�2/�9p3���(� <br /> SUBCONTRAC TOW CONSULTANT ADonss 3140 Gold Camp Dr.#160 Crry1STATFJzIP RanchQ_][=QY_a,CA 95670 <br /> LICENSE XC-57 C-61 D-09 OSI'{'i NUMBER 899451 EXPIRATION DATE 06/30/2021 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SANPuNO: General Mineral/Coliform Bactena(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE D::mesLUPnvate Ingabon/Agrlculturai Industrial Water Duality Monitoring X Sod Sampling/Characterimon <br /> Public Water System <br /> In ddlen,14 ncm C-1 Wafer v.>tem Nu Ccritaa Narro x P ror NurMer <br /> TYPE OF WORK New Well Raplacement'Nell Well Alterauon.Moddlcatwn Other <br /> Monitoring Welds! 0 o!wells Sal Bonngls) I°r X Geotechn cal <br /> Out-01-Service Well Out-01-Service Well Renewal Cross-Connoctkon Repair <br /> Now Pump Pump Replacement Plump Repair Raise Well Casing <br /> WELL CONSTRVCTION <br /> Drilling Method Mud Rotary Air Rotary X Auger Cade Tool Push Paint Other <br /> Proposed Well Depth 50 It Excavation 1.5 in diameter Open Bottom Gravel PacW'Gravel S¢e in diameter <br /> Conductor Casing In diameter 1 Conductor Casing Depth It <br /> Well Casing Diameter_in TAIclmessrGauge ASTM Schell Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 R X Neat Cement(94 1b bao.10 gal water) Sand Cement sack mix.7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall X Other CPT rodSIVBmmie Retardant/Accelerator(name) <br /> PEDESTAL Installed By DnRer Pump Contractor Other ------ <br /> Concnste Pedestal Dimensions Width R Length R Thick in Christy Box Stove,,. <br /> PSL Submersible Ttebmi, OIrTr HP Pump Se! 7 SIa^r,,ng Wwri,Le,ei R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUN Y ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND CTIWITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP TION AWS <br /> MID11G' 4 'ADVANCE CE REQUIRED F INSPE IC' I AAES��E CALL(209))953E-7697 <br /> SIGNED TITa DATE `�/►�� <br /> RF yMF <br /> C�cj V�T <br /> U� <br /> 44, oq 30?420 <br /> IRQONq IN -OU <br /> DFP � � <br /> � �y <br /> '�7/J/DEPARTMENT BE ONLY <br /> Application Accepted By �f--'�� Data 7 � O Area .S rC�C Employer-IDR lk <br /> Gro„t Inspecnon By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Shc Boring Inspection By Date Constructed Well Depth h <br /> COMMENTS <br /> PE SC I Codes Info Received A. Remdad tie PWMW RequestSWvlcg e Invoke B Wad IDR <br /> N372 S-0 ' <br /> EHD4106 4112919 WELL-4.00P PERMIT <br />