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e <br /> • 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 1780 Whirlaway Lane CITY/ZP Tracy, CA 95376 <br /> Encanto Lane 244-020-400 625sQ 3,7' cf up g <br /> CROSS STREET APN PARCEL SIZE LAN S dE PLICATION A <br /> OWNER NAME City of Tracy-Dept.of Public Works PHONE 209-831-6366 N <br /> OWNER ADDRESS 520 S.Tracy Boulevard CITYISTATEIZIP Tracy,CA 95376 <br /> CONTRACTOR AESCO PHONE 714-375-3830 <br /> CONTRACTOR ADDRESS 17782 Georgetown Lane CITY/STATEIZIP Huntington Beach,CA 92647 <br /> SUBCONTRACTOR/CONSULTANT Moore Twinning PHONE 559-313-5851 <br /> SUBCONTRACTOWCONSULTANT ADDRESS 2527 Fresno Street CITYISTATE/LP Fresno,CA 93721 <br /> LICENSE )(yyC-57 ❑C-61 ❑D-09 L]Other NUMBER 506159 EXPIRATION DATE 2-28-21 <br /> BILLING PARTY: F OWNER FYCONTRACTOR n SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:a General Mineral/Coliform Bacteria(4391)u Dibromochloropropane(4392)u Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private C Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring A Soil Sampling/Characterization <br /> ❑Public Water System <br /> K different from Omer: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well Replacement Well ❑Well Alteration/Modification C Other <br /> ❑Monitoring Well(s) #of wells 7 Soil Borings) #of borings X Geotechnical 1 #of borings <br /> Li Out-Of-Service Well a Out-Of-Service Well Renewal a Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method a Mud Rotary a Air Rotary a Auger L Cable Tool a Push Point LX Other Hollow Stem Auger <br /> Proposed Well Depth qrb_it Excavation in diameter C Open Bottom 7 Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad L Steel a Plastic u Stainless Steel a Other <br /> Grout Seal Depth�ft n Neat Cement(941b bag/5-10 gal water) n Sand Cement sack m/xl7 gal water <br /> ),Bentonite(20%solids) L Other <br /> Grout Placement Method Pumped Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller :1 Pump Contractor 7 Other <br /> ❑Concrete Pedestal ODimensions:Width it Length it Thick in C Christy Box :1 Stove Pipe <br /> PUMP n Submersible Turbine n Other HP Pump Set It Standing Water Level it <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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_0� TITLE Project Manager DATE 12-14-20 <br /> CY�F <br /> Fi� T <br /> s ✓ ?y?O?O <br /> O <br /> CO <br /> R 4 <br /> FN7. <br /> DEPARTMENT USE/NL Y <br /> SE NLY <br /> Application Accepted By 4 Date /Z Or'o Area �- Employee ID# rM <br /> Grout Inspection By DateV'I ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received l <br /> Soil Boring Inspection By Date Constructed Well Depth ftr H /bg yf tori{/Q <br /> COMMENTS e •✓3 t. ,.J IIt t 0 Ft?ti} t! v <br /> Cu r-J,L: nr diti�C r!I n�pg�tCl w/Aih 30 � J*D/P rr a ra v f wi{I be t:sr4. <br /> PE sc Received Check#/ Amount Permit/ <br /> Codes Info ash Remitted ata eR at Invoice# We111D# JASM4I��tt�Jn 4T <br /> 37a / 5 ea benfooJ9 <br /> or bet40(I <br /> A racks. <br /> EHD 43-O6 6/11@019 / � WELL/PUMP PERMIT <br /> ll�v�8'9Z2-(� <br />