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WELL/PUMP PERMIT <br /> SAN JOAQUIN COONTT ENVIRONMENTAL HEALTH DE PAR TMEN- 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)466-3420 <br /> NON-REFUNDABLE PERMIT www.Ejgc,y.Orq/ehd___ _ EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 50d ML Oso Avenue _-__. CITrILP Tracy CA 95m— e1 <br /> CROS3 STREET S Trac(Blvd APIN 23510010 O PARCEL SIZE f„. LAND USE APPLICATION a 9�9 <br /> T <br /> OWNER NAME Tracy Unedh�QsiticL PHS 209-830-3200 <br /> OWNER ADDRESS __1875.W Lowell Avenue _ CrrrrSTATvz,, Tracy,CA 95376 <br /> CONTRACTOR Middle Earth Geo Testing Inc. PNoNE 714-633-5025 <br /> CONTRACTORADDREss 954 N Lemon Street CITY/STATFJZIP Orange, CA 92767 <br /> SUBCONTRACTOR(CDNSULTANT BSK Associates PNoNE 916-853-9293 <br /> SUBLOWRACTOWC ONSUL TANI ADDRESS 3140 GQid Camp Dr.#160_ CITrfSTATE1ZIPf jaMb" rdoya.CA 9-5670 <br /> LICENSE :?657 C-lit D^g Other NuMtsER 899451 ExPrRATioN DATE <br /> .Q6/30/2021 <br /> BILUND PARTY. OWNER CONTRACTOR X SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Baclena(4391) Dlbromochloropropane(4392) Arsenic(4393) <br /> FW-W-1m USE Dcrr-sticipnvate IrrigatiorvAgrxultUral Inclustnal 'Nater Quality Monitorrlg X Sal Sampling/ChwacteriZa;ron <br /> Public Water System <br /> N do-l trent parer 'rleier SIV—Nr CorMC Nary w PNpna Nu.nee, <br /> TrPE Or WARN New Well Replacement Well Well AlteraboniLlodtfcabon Other <br /> Monlormg WeEI_s) N of welts Sal Bormgts) a"r X Geolechr!cal�Ndtanias <br /> Out-Of-Service Well Out-Of-Service Weil Renewal Cross•Connoctwn Repair <br /> New Pump Pump Replacement Pump Repan Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Ar Rotary X Auger Cable Tca Push Point Other <br /> Proposed Well Depth 50 R Excavation 1.5 in diameter Open Bottom Gravel PaULGravet Sao in diameter <br /> Conductor Casing In diameter I Conductor Casing Depth 11 <br /> Well Casing Diameter_in Tri chress/GaugerASTM Sched Simi PI stk; Stainless Steel Other <br /> Grout Seal Depth 50 it X Neat Cement(94 Ib bag/5•10 gat water) Sand Cement sack mix,-7 gal water <br /> Bentonite(20%solids) Other <br /> Groul Placement Method Pumped Free Fall x Other CPT rocIS/lremmle Retardant I Accelerator(name) <br /> !PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width h Length h Thick In Christy Box Stove Pipe <br /> PUMA SUbnmro.ble TurC•nr Other HP Pump Set 1 Standing Water Level it <br /> I HEREBY CER FY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COON ORDINANCES. STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND T1VE WITH T E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP ATION LA <br /> t ;hi^ R VANCE NOTICE REQUIRED FQ'rNIIN�SPE IOSN yy1P(L��7���p'SE CALL 1209)953-7697 <br /> SIGNED TITLEFiY~``sIrk1 �r" IA�-V,, DATE <br /> E yMFN <br /> C�c�VF� <br /> A QU/N <br /> D pgRr ENrY <br /> r <br /> DEPARTMENT USE NlY <br /> Appl,caton Accepted By � � Date Arae -G Empbyes IDM k <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date _ WAIVER Received <br /> Sol Bang Inspection By 0a1e Constructed Well Depth h <br /> COMMENTS <br /> PE 8C RweMd Chm*W An cunt Deb Permit Invoke 8 Well IDN <br /> Coda Into Reedlled Servlu R711A 3111Z <br /> e <br /> �137d <br /> EMO aXIE 6't t 40t9 AELL 1'I4rP PERMIT <br />