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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 1090 S Central Pkwy (Mountain House HS) cITY/zIP Tracy CA 95391 m <br /> D <br /> CROSS STREET Mustanq Way APN 20945030 PARCEL SIZE LAND USE APPLICATION# o <br /> A <br /> m <br /> OWNER NAME Lammersville Unified School District PHONE (209)836-7400 N <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 N Lemon Street CITY/STATE/ZIP Orange, CA 92767 <br /> SUBCONTRACTOR/CONSULTANT BSK AssoClateS 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 0-09 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) 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 Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) x of borings X Geotechnical_2p 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 20-50 It Excavation 1.5 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 20-50ft X Neat Cement(94/b 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 i 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 AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKER MP NSATION LAWS. <br /> n 48 OUR ADVANCE NOTICE REQUIRED F 1 ISPECC 11oN� -PL E C L 209)953-77697 <br /> SI TITLE " DATE�Z'L V 7' <br /> l FC �FNT <br /> 2020 <br /> V/N <br /> I I 1 #1 1#1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> FnIT <br /> DEPARTMENT USE ONLY <br /> �- cc <br /> Application Accepted By Date iv �u 'Uri. Area 9 Employee ID# L'- <br /> Grout Inspection By Dale L SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constucted Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ �+` t�, • <br /> Codes Info Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> 4(7;ogIiA I 15 <br /> DMD 47-06 6111/20 19 //�, ` �/ Q'C��L/�y WELL/PUMP PERMIT <br />