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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 /> JOB ADDRESS 452 W Francis Ave. (Altamont ES) ciTYaIP Tracy, CA 95391 4 <br /> CROSSSTREET N Covina Street APN 25614001 PARCEL SIZE) ja!_AND USE APPLICATION# A <br /> m <br /> OWNER NAME Lammersville Unified School District PHONE (209)836-7400 N <br /> OWNER ADDRESS 111 De Anza Blvd. crry/sTATEmp Tracy,CA 95391 <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street cmy/STATEmp Escondido, CA 92029 <br /> SUBCONTRACTOR/CONSULTANT BSK Associates PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONsuLTAwADDREss3140 Gold Camp Dr.#160 crry/sTATE/zp 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 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 Nam Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bodng(s) ft of borings x Geotechnical�_#of borings <br /> Out-Ot-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 Too] 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(94 lb 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 It Length It Thick in Christy Box Stove Pipe <br /> au—MP 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 /> MINIMUM4j3 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ,�L,•,,If ~y TITLE Owner DATE 12/29/2020 <br /> c MFNr <br /> 44 <br /> C <br /> qR��NTY <br /> FNT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date a ao Area S �� Employee ID#,�_0 <br /> k1 <br /> Grout Inspection By . - Date "I2 1 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection IV Date Co strutted Well Depth ft <br /> COMMENTS C <br /> uv <br /> Irt'111 — <br /> PE SC Received Check#/ AnrilSunt Date Permit/ Invoice# Well ID# <br /> Coders Info7� AVA Cash Remitted Service Request# <br /> 3/a D r <br /> EHD43-06 611112019 //96�34/ WELL!PUMP PERMIT <br />