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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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 3OO N <br /> F�pgary Dr, (Wi .kl Ind S) aTY/ZIP_Tracy. CA 95376 <br /> m <br /> O <br /> CROSS STREET S Providence Street APN 25404004 PARCEL SIZE �- + LAND USE APPLICATION# p <br /> A <br /> OWNER NAME Lammers -vill nifi d hoof District t PHONE (209)836-7400 y <br /> OWNER ADDRESS 111 De ArTZa-Blvd ,f/ I Y` j-t [ 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 Assnriates J1 PHONE_916-853-9293 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr.#1 60 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 Syslem Name Contac Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) It of borings X Geotechnical�_"or coring, <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 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 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 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 /> Pu 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 /> !aRRENj AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKEROMPENSATIO LAWS. <br /> U 48 UR ADVANCE NOTICE REQUIRED FOR PEaTIS�(-(�'L,�. CFS'..' (?'9)9�]53- 69 7 <br /> SIGNED TITLE IVV�VCC..�� A E I l r��'2P <br /> 7_777 <br /> i <br /> I 1 F FNT <br /> _ QED <br /> _ � 1 <br /> 312020 <br /> U/ <br /> HuNry <br /> gRro L <br /> MFNT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L�L- Date f/ J p-'L. Area -/"K,. Employee]D# <br /> Grout Inspection By L Date '-V SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS .(�1 GA t_� t_ 4 ��' D �G C �'� ✓r��A ��5 '1 t"t <br /> PESC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Into Cash Remitted Service Re uest# <br /> EMD 47-06 6111/3079 ���f[^��/��] WELL/PUMP PERN97 <br />