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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 /> LJOB ADDRESS 685 N Montebello St. (Questa ES) CITYmP Tracy, CA 95391 bLn <br /> CROSS STREET W Gravino Drive APN 25650003 PARCEL SIZE ib.ol LAND USE APPLICATION# A <br /> m <br /> OWNER NAME Lammersville Unified School District <br /> 1inA^ "� PHONE (209) <br /> N <br /> OWNER ADDRESS 3l� LCITY/sTATEmP MiJ(,AfeA;A <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street c,/STATE/LP Escondido, CA 92029 <br /> SUBCONTRACTOR/CONSULTANT BSK Associates PHONE 916-853-9293 <br /> SUBCOWRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr.#160 crry/sTATEmP 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 SUBCONTRACTORICONSULTANT <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 Omer 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 Borings) #of borings X Geotechnical 3 of borings <br /> Out-Of-Service Well 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 Auger Cable Tool Push Point Other <br /> Proposed Well Depth 15 ft Excavation 6_8 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 15 ft x Neat Cement(941b 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 /> PEDESTAL 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 it Standing Water Level it <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 /> MIINIMUM.48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED .�f.a��•"�' TITLE Owner DATE 12/29/2020 <br /> F SMF <br /> .01 <br /> q4 Qu <br /> cF��or <br /> c <br /> 3,�0 <br /> N <br /> pqIV;,,�NTY <br /> RTMNr <br /> /DEPARTMENT USE ONLY n <br /> Application Accepted By `�'� Date�'� a O.W Area 5 ��� Employee ID# els <br /> Grout Inspection By 0 Date T I2(�2� SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> SoilRA= <br /> Date Con tructed W)II De th ftCOMMe F V� I GYDV ►Va er-terNU AYO (IRA QI/ <br /> 13 <br /> PE SC Received Check#/ Amount Date Permitl Invoice# Well ID# <br /> Codes Info B Cash Remitted Re uest# <br /> �a so Service <br /> EHD 43.06 611112019 � /�� J�� <,/ _ WELL(PUMP PERMIT <br />