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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 500Mt. Oso Avenue cITYmP Tracy. CA 95376 m <br /> D <br /> CROSS STREETS Tracy Blvd APN 23510010 PARCEL SIZE Of IC{ LAND USE APPLICATION# A <br /> m <br /> OWNER NAME Tracy Unified School District PHONE 209-830-3200 <br /> OWNER ADDRESS 1875 W Lowell Avenue CITYISTATEIZIP Tracy, CA 95376 <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street CITY/STATEIZIP Escondido, CA 92029 <br /> SUBCONTRACTORICONSULTANT BSK Associates �.i PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANTADDRESS 3140 Gold Camp Dr.#160 CITYISTATE/ZIP Rancho Cordova, CA 95670 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 804318 EXPIRATION DATE 02/28/2022 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private 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 Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) #of borings X Geotechnical 2 °(borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 15 ft Excavation 6-8 in diameter Open Bottom 1 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 15 ft X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped X Free Fall Other Retardant/Accelerator name <br /> 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 /> MINIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNEDif`/L�.,,)� �• TITLE Wner DATE 7/27/2020 <br /> 4 qY <br /> cF ANT <br /> _ I I <br /> Eo <br /> 30?p?0 <br /> ' v�N <br /> L_p <br /> F NMENpUNT f' <br /> P,gRTMENT <br /> H-41 11 <br /> / DEPARTMENT USE,ONLY <br /> Application Accepted By Dale 7 �0,;Ii 0 Area/r't y Employee ID# <br /> Grout Inspection By Date SPECIALTWeII Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date .�� Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service ftuestA, <br /> `1137� 1�1'0 ��x awl vi D <br /> EHD 43-06 6/11;2019 WELL(PUMP PERMIT <br />