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WELL/PUMP PERMIT <br /> SAA JOAQUIN COUNTY ExvIRONMENTAL HEALTH DEPARTMENT 1968 EAST HAZELToR Ave Nue•STOCKTON CA 95205-6232(209)466-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 9895 Holly Drive ____.. ciTYmP Tracy,CA 95376 <br /> CROSS STREET Kavanagh Ayenli P. APN 21450002 PARCEL SIZE LAND USE APPLICATION R <br /> OWNER NAME _Tracy Unif e_d SchooLDatncl_ _ _ PHONE 209-830-3200 <br /> OWNER ADDRESS 1875 W Lowell Avenue-_-, _ crrYrsTA.uz,P Tracy. CA 95376 <br /> CONTRACTOR Middle Earth Geo Testing Inc. PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 N Lemon Street crrrrwArERIP Orange,CA 92767 _ <br /> SUBCONTRACTORICONSULI'Ve RRK cc .fates ___.. PHONE 916-853-9293 <br /> SUBCONTRACTORlCONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CIT'r!STATE/zIP Rancho Cordova. CA 95670 <br /> LICENSE x C-57 C-6t 0.09 Ot--,, NUMBER 899451 ExPIRATIDN DATE 06/30/2021 <br /> SWUNG PARTY: OWNER CONTRACTOR a SWONTRACTORICONSULTANT <br /> DOMESTIC WELL SArpusio: General Mineral/Coliform Bacteria(4391) Dlbromochloropropane(4392) Arsenic(4393) <br /> IME14DED USE DcmesbUPrivale Irrg7atioNAgricultural Industrial Water Quality Monitoring X Soll Samp6ngiCharactentretion <br /> Public Water System. <br /> X d4?—t bum O i, 'Wait,Spleen Name Carted Name d Pitts Nun", <br /> TYPE OF WM New Well Replacement`Nell Well AReraborVModfiCBtion Other <br /> Mondonng Welk S) N of wells Sal Bonng(s) t o1 s'dr"w, X GeoleUn,al <br /> W-Of-Service wee 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 Air Rotary X Alger Cable Tool Push Point Other <br /> Proposed Well Depth 5011 Excavation 1-5 :n dometer Open Bottom Gravel Pack/Gravel Size in Gameter <br /> Conductor Calling in diameter 1 Conductor Casing Depth M <br /> Well Casing Diameter_ in ThldcneavGaugeiASTM Scheid Steel Plastic Stainless Steel Other <br /> Grout Seal Depin 50 it X Neat Cement(94 Ib beg/5•10 gal warerl Sand Cement __sack mnu7 gal water <br /> Bentorvte(20%soils) Other <br /> Grout Placement Method Pumped Free Fag X Other CPT rOdS/tremmle Retardant I Accelerator tname) <br /> 'PEDESTAL InsWledBy OriBer Pump Contractor Other <br /> Concrete Pedestal DMnsNNons.Width R Length R Thick n Christy Boa Stove Pipe <br /> Submersible Turomr Other HP Pump Sal 9 Standing Wa:ar Lnve. R <br /> IHEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> J OAQUIN COU Y ORDINANCES. STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AN A E WITH E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C N9 TIO LkVANCE <br /> MINI 4 NOTICE REQUIRED FO INSPE 10 S-PL ASE C�A,�.(209)953-7697 <br /> SIGNED— <br /> TITLE kii t DATE ZD;' <br /> 7-2� b <br /> RE CFYMEN <br /> �V�� <br /> 30 <br /> /if,pN IN COU <br /> HOEpq����T <br /> DEPARTMENT USE ONLY / <br /> Appircalan Accepted By Date 7 O7 Dai Area`� Ic!f'L Employee IDN <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Sol Bnnng Impaction By� 7L AT �tN�Date�n Constructed Well Depth _ R <br /> COMMENTS <br /> Codes IMS PIE SIC Received r ChsSW <br /> AmounRemitted tgdt Dsh rvlusrmilif <br /> R t N Invoke r Well Will <br /> 717 S <br /> EHDA1os 5,112019 WELL VUUP PEM-47 <br />