Laserfiche WebLink
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 1140 Durant Terrace (Hansen ES) CITY/ZIP Tracy, CA 95391 m <br /> D <br /> CROSS STREET Holt Avenue APN 26202019 PARCEL SIZE LAND USE APPLICATION# p <br /> OWNER NAME Lammersville Unified School District PHONE (209) 836-7400 e! <br /> OWNER ADDRESS 111 De Anza Blvd. CITY/STATE/ZIP Tracy, CA 95391 <br /> CONTRACTOR Middle Earth Geo Testing, Inc. PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 NLemon Street CITY/STATE/ZIP Orange, CA 92767 <br /> SUBCONTRACTOR/CONSULTANT BSK ASSOCIates PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANTADDRESS 3140 Gold Camp Dr. #160 CrTY/STATE/ZIP Rancho Cordova, CA 95670 <br /> LICENSE X C-57 C-61 D-C9 Other NUMBER 899451 ExPIRATION DATE 06/30/2021 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochlorcpropane(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: Wale,Sysi—Name Co.t-1 Name ar Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) x of bogs 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 ft Excavation 1.5 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 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 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 ft Standing Water Level fl <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 /> CURRE T AND ACTNE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKS S COMPEN TION LAWS. l <br /> )A�M M 8 HOUR DVANCE NOTICE REQUIRED F ` INSPE��IOh ;,p /SEy�C/yQr�L�(r�09)953-7¢9 7 � <br /> SIGNI. TITLE VVJJJ111' IU'�- W!(yl/If/XATE �1Z�f <br /> C 3 l ?p?0 <br /> QU/N C <br /> T FP E/V OU NTy <br /> ART47E/VT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By /����� Date fad S'i!dJiu'l' Area �� Employee ID# /'- <br /> Grout Inspection By t-1. Dater\ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By — Oale Constructed Well Depth ft <br /> COMMENTS 1� i' \v lJ\\ —ir A ,y b y two L 11�t" <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info B Cas Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 6111/2019 `/Q�7�(�--y WELL/PUMP PERMIT <br />