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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 /> Joe ADDRESS _570 S Escuela Dr. (Bethany ES) CITY/ZIP Tracy CA 95391 m <br /> n <br /> CROSSSTREET Puente Drive S APN 25423009 PARCEL SIZE LAND USE APPLICATION# o <br /> A <br /> OWNER NAME Lammersville Unified School District PHONE (209)836-7400 y <br /> OWNER ADDRESS 1 1 1 De Anza Blvd, T DTIV CITY/STATE/zIP Tracy,-CA_g5391 jS3 C1 <br /> CONTRACTOR Middle Earth Geo Testing, Inc. PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 N Lemon Street CITY/STATE/ZIP Orange, CA 92767 <br /> SUBCONTRACTOR/CONSULTANT BSK Associates u PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CITY/STATE/ZIP Rancho Cordova, CA 95670 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 899451 EXPIRATION DATE 06/30/2021 <br /> BILLING PARTY: OWNER CONTRACTOR n 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 ICharactenzation <br /> Public Water System <br /> If different from Owner: Water System,Name Contact Name or Pnone 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_�#of oonngs <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 50 it Excavation 1.5 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter i Conductor Casing Depth 11 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 it X Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mrx/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall X Other CPT rods/tremmie 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 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 AN ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKER C PENSATION LAWS. <br /> 1;' HOUR A NCE NOTICE REQUIRED IF R INSPECTIaNS- LE CALL(2 9)953-769 / <br /> I <br /> SIGNE TITLE E �-- <br /> r ��/^^• <br /> L `a <br /> f , s <br /> '?o"0 <br /> R i <br /> 00/v <br /> 1rN� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L L `I } <br /> Date ✓ -sJ �i%✓� Area �i Employee ID# / <br /> Grout Inspection By Date 2 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info -By,--% Remitted Date Service Request# Invoice# Well ID# <br /> EHD CJ Oti 6/71/2019 , 2 WELL(PUMP PERMIT <br />