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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.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS 1090 S Central Pkft(Mountain House HS) ciTyrzipTracy. CA 95391 �yyy <br /> CROSS STREET Mustang Way APN 20945030 PARCEL SIZE Jo; LAND USE APPLICATION 4 <br /> OWNER NAME Lammersville Unified School District PHONE(209) 836-7400 m <br /> OWNER ADDRESS 111 De Anza Blvd. cfrvrsTATEmP Tracy. CA 95391 <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street CIT1dsTATEi iP Escondido, CA 92029 <br /> SUBCONTRACTOR/CONSULTANT BSK Associates �y PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 31 40 Gold Camp Dr.#1 60 CrrylsTATE2IP Rancho Cordova, CA95670 <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 Boring(s) a of borings x Geotechnical 4 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(94 lb bag/5-10 gal water) Sand Cement sack mix17 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 It Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Zt`/A.J/� Al - TITLE mer DATE 12/29/2020 <br /> FgYM <br /> S c 3� Fo <br /> ? <br /> ��� <br /> opo <br /> pAR <br /> °4 7*k <br /> FNT <br /> � dDEPARTMENT USE ONLY <br /> Application Accepted By Date 01aC O iV Area Employee ID# /y <br /> Grout Inspection By to SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Borin Ins ection Date s L.CC.onstru ed 01 Depth ft <br /> COMMENTS gQY11�e -*' _ t/SP f GW'l HT-�f!Yli'IIv,✓t7E''TP i�+O p ,Y <br /> it)NV P r� rx\\ N 60 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted S rvice Re uest# <br /> -1 37d so a 5 <br /> EHD 43-06 6/11/2019 /� /t- ' //��--r �c1�^7 WELL/PUMP PERMIT <br />