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� T <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 2815 Holly Drive CITY21P Tracy. CA 95376 <br /> CROSS STREET Kavanagh Avenue APN 21450002 PARCEL SIZE--9-LAND USE APPLICATION# <br /> OWNER NAME Tracy Unified School District PHONE 209-830-3200 w <br /> OWNER ADDRESS 1875 W Lowell Avenue CITY/STATE21P Tracy, CA 95376 <br /> CONTRACTOR Baia Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street CITY/STATEmP Escondido,CA 92029 <br /> SUBCONTRACTORICONSULTANT BSK Associates ��yy PHONE 916-853-9293 <br /> SUBCONTRACTORICONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CITY/STATEmP Rancho Cordova, CA95670 <br /> LICENSE X C-57 C-61 D-09 7 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)G Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural C Industrial C 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 -1 Replacement Well F Well Alteration/Modification Other <br /> Monitoring Well(s) 4 of wells Soil Boring(s) #of borings X Geotechnical� �of borings <br /> i Out-Of-Service Well C Out-Of-Service Well Renewal L Cross-Connection Repair <br /> i New Pum i_I Pump Replacement 7 Pump Repair G Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary i7 Air Rotary X Auger ❑Cable Tool ❑Push Point -I Other <br /> Proposed Well Depth 15 ft Excavation 6-8 in diameter Open Bottom I I 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 c Steel i Plastic r I Stainless Steel ❑Other <br /> Grout Seal Depth 15 It X Neat Cement(94 Ib bag15-10 gal water) 7 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method C Pumped X Free Fall Other ❑Retardant/Accelerator name <br /> Installed By Driller : Pump Contractor 7 Other <br /> Concrete Pedestal _Dimensions:Width ft Length ft Thick in Christy Box L Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It Ste ding 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. 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 /> NIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED L�.J� o <br /> 7 TITLE Owner DATE 7/27/2020 <br /> Ljf- RFq yMF <br /> U� <br /> cF��EO <br /> ogQ�30?0?0 <br /> A`N� <br /> 4Fe <br /> DEPARTMENT USE ONLY <br /> Date 7O <br /> �Y' <br /> Application Accepted By O J Area S / L Empinyee v#_ <br /> i� <br /> Grout Inspection By Date J SPE AL Well Permit <br /> Pump Inspection By Date ^I, WAIVER Received <br /> Soil Boring Inspection By q^ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Into Remitted Service Re uest# <br /> EHD 43M 6/1112019 WELL/PUMP PERMIT <br />