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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 452 W�t Fran is Ave, (Altamont S) cm/zIP_Tracv. CA P5121 0 <br /> ( ( m <br /> CROSS STREET N Covina Street APN 25614001 PARCEL SIZE I J^.L 1 LAND USE APPLICATION fi I <br /> OWNER NAME <br /> -Lammers0le Uriefied School District PHONE (209)836-7400 tn", <br /> OWNER ADDRESS 111 De Anza Blvd. CITY/STATFJZIP Tracv, 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 /> SUBCONTRACTORICONSULTANT BSK Accocintes PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CITY/STATE(ZIP Rancho Cordova CA 95670 <br /> fLICENSE f C-57 C-61 "9 Other NUMBER 896451 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 /> It oiMereni hom Owner Water s"t—Name Cuncaci Name or Phone N;.mber <br /> TYPE OF WORK New Well Replacement Well Well AlterationlModifiemion Other <br /> Monitoring Wells) #of wells Soil Boring(s) °of be6091 :-:Geotechnical of bon p <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 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_.n Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 ft X Neat Cement(94!b bag/5-10 gat water) Sano Cement sack mix:0 gal water <br /> Bentonite(20%solidst 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 It Thick in Christy Box Stove Pipe <br /> &-P Submersible Turbine 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 ORD I NCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE ITN THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CPAPENSAT LAWS. <br /> M UR ADVANC NOTICE REQUIRED FOF{�I SPECTk S�kE-ASECAL )) <br /> 913-7691 <br /> SIGNED TITLE '�j' E f/ - O 17i V <br /> i Pq�'MF <br /> �cE/VED <br /> "AV 4�i 3 202 <br /> } l <br /> Qu//v pgFNo/vT' <br /> RTNjFNT <br /> DEPARTMENT U E NLY <br /> Application Accepted By G Dale 3 00&0 Employee[D#As <br /> Grout Inspection By Dale SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Check#/ Amount at Permit/ Invoice# Well IDM <br /> Codes Into Cas Remitted ServiceRe nest# <br /> `872 )S-b 4 qsj�, <br /> LHD43-36 $11112019 WELL tPUMP PERMIT <br />