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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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 1140 Durant Terrace (Hansen ES) CITY/Zip Tracy, CA 95391 rpDD <br /> CROSS STREET Holt Avenue APN 26202019 PARCEL SIZE&`LAND USE APPLICATION# A <br /> m <br /> OWNER NAME Lammersville Unified School District PHONE (209) 836-7400 H <br /> OWNER ADDRESS 111 De Anza Blvd. CITY/STATE/ZIP Tracy, CA 95391 <br /> CONTRACTOR Bala Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street CIN/STATE/ZIP Escondido, CA 92029 <br /> SUBCONTRACTOR/CONSULTANT BSK Associates �t PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CITY/STATE/ZIP Rancho Cordova, CAp 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 SAMPUNG: 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 /> It 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) tt of borings x Geotechnical�_N 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 ft <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 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 It Length It 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§ <br /> HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ,�it,.aIf AV— TITLE Owner DATE 12/29/2020 <br /> RE SMF <br /> CFjV�T <br /> F�3 <br /> s q Q� <br /> RO/V IN CO <br /> oEpgR MENT y <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �— DateOel IVA' Area Employee ID# <br /> Grout Inspection By Date G Z SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Ins ectioryBy Dat Construfted Well Depth ft <br /> COMMENTS Oi/ NI pT. '4 f"yP^r✓/ <br /> �1 i'� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info AM. Cas Remitted Service Re uest# <br /> WELL/PUMP PERMIT <br /> EHD 43-06 6/11/2079 <br />