Laserfiche WebLink
r � <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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1550 Cypress Drive crrymp Trac[., CA 95376 m <br /> D <br /> CROSSSTREET Alden Glen Drive APN 23425001 PARCELSIZE ay.I LAND USE APPLICATION# A <br /> In <br /> OWNER NAME Tracy Unified School District PHONE 209-830-3200 y <br /> OWNER ADDRESS 1875 W Lowell Avenue CITY/STATE/zip Tracy, CA 95376 <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street CITY/STATE2IP Escondido,CA 92029 <br /> SUBCONTRACTOR/CONSULTANT BSK AssociatesPHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CITY/STATErzIP Rancho Cordova, CA 95670 <br /> LICENSE X C-57 i C-61 !1 D-09 J Other NUMBER 804318 EXPIRATION DATE 02/28/2022 <br /> BILLING PARTY: .OWNER LI CONTRACTOR X SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)[]Arsenic(4393) <br /> INTENDED USE Domestic/Private C 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 F Well Alteration/Modification =,Other <br /> Monitoring Well(s) #of wells Soil Boring(s) a of borings X Geotechnical of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal F Cross-Connection Repair <br /> New Pump C,Pump Replacement 1 Pump Repair -i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Air Rotary X Auger G Cable Tool ❑Push Point 1J Other <br /> Proposed Well Depth 15 ft Excavation 6-8 in diameter 7 Open Bottom I I Gravel Pack/Gravel Size in diameter <br /> Li Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel I Plastic I Stainless Steel ❑Other <br /> Grout Seal Depth 15 ft X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) IOther <br /> Grout Placement Method Pumped X Free Fall Other Retardant/Accelerator name <br /> IPEUESIAL Installed By 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 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 /> MINIMUMy,48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED/L/�t..���•(~� TITLE Owner DATE 7/2712020 <br /> %E�c <br /> A,7- <br /> F�vt6 <br /> 1A 3 0 Z020 <br /> rIVN <br /> 4411 l pE A /V 7.4TAIIL Y <br /> T <br /> DEPARTMENT USE ONLY {� <br /> Application Accepted By Date 7 Area Employee ID# / <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received CCLef Amount Date Permit/ Invoice# Well ID# <br /> Codes Into Remitted Service Re uest# <br /> /• StJ A <br /> EHD 4106 6111/2019 WELL/PUMP PERMIT <br />