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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 685 N Montebello St (O I .sta S) CITY/ZIP Tracy. CA 95391 m <br /> CROSS STREET W Gravino Drive APN 25650003 PARCEL SIZE LAND USE APPLICATION# O <br /> A <br /> OWNER NAME Lammersville Unified School District PHONE (209) 836-7400 H <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 Associates �y 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 X SUBCONTRACTOWCONSULTANT <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 dilfe nt I—Owner. Water System Name Contact Name or Pnone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring WBII(s) #of wells Soil Boring(s) At of borings X Geotechnical 1 k or borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casio <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 / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 ft X Neat Cement(94/b bag/5-f0 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 If 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 /> 4E OUR-,ADVANCE NOTICE REQUIRED FO "SPE NS•PI E CA�/�jy1209)953-�7(697 /�SIG D 1 TITLE V ( - DATE IZy7r/ -ZV <br /> RE /VP <br /> FC 3 , ?0?0 <br /> /. Oq QU/ <br /> lH'D R/V� NTy <br /> _ T MINT <br /> ]i / DEPARTMENT USE ONLY <br /> Application Accepted By L- Date Area Ct c l Employee ID# <br /> Grout Inspection By N• v Date , 2 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS \ ��'� t SC �P�Dr IOgrl\��, G ACO \ tat l USCI t "t r <br /> T <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well IDN <br /> Codes Info Cas Remitted Service Re est# <br /> r 3 7.7 111 <br /> EHD 00-06 8/11/2019 /L 66 31 J,/, WELL/PUMP PERMIT <br />