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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 /> to <br /> JOB ADDRESS 570 S Escuela Dr. (Bethany ES) crrymP Tracy.CA 95391 <br /> CROSS STREET Puente Drive S APN 25423009 PARCEL SIZE IS LAND USE APPLICATION# <br /> OWNERNAME LammersAlle Unified School District PHONE()836-71400 � <br /> OWNER ADDRESS . 3C0 Is <br /> GJ_(_VSD r- CITYISTATE21P '°(J�Ij�W✓I I�:Jr '. �'S 3 Cf 1 <br /> CONTRACTOR Baia Exploration PHONE 760-743-7678 1 <br /> CONTRACTOR ADDRESS 1915 Commercial Street c,,sTATEmP Escondido, CA 92029 <br /> SUBCONTRACTOR/CONSULTANT FISK Associates PHONE 916-853-9293 <br /> SUBCONTRAOTORICONSULTAW ADDRESS 3140 Gold Camp Dr. #160 CITYISTATE/2]P 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 SU13CONTRACTORICONSULTANT <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 Boring(s) u of borings x Geotechnicalofof 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 Schad 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 ft 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 /> �f <br /> SIGNED�l+r�^" TITLE Owner DATE 12/29/2020 <br /> c MFN <br /> ��VFO <br /> N <br /> H R 40�NTY <br /> FNT <br /> DEPARTMENT USE ONLY /2 <br /> Application Accepted By Z-�Z— Date d C?,,?JaQ Area S- Employee ID# <br /> Grout Inspection By Date Z\ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection YyDate Constructed Well Depth ft <br /> COMMENTS �fPf je- -b big yr-:F� / e'frsV1?�' WC9 V�c Pl- W//126ae / <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By^ <br /> Cas Remitted Service Request# <br /> 14374 1,50 <br /> EH043-06 6/1112019 /X? <br /> /11/2019 //4 WELL/PUMP PERMIT <br />