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JOB ADDRESS 200 W Eaton Avenue <br />CROSS STREET Parker Avenue APN 23314028 <br />cireizip Tracy, CA 95376 <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME <br /> Tracy Unified School District PHONE 209-830-3200 <br />OWNER ADDRESS 1 7S W I nwRil AvPnUA. ortisTATErzip Tracy, CA 95376 <br />CONTRACTOR Baia Exploration PHONE 760-743-7678 <br />CONTRACTOR ADDRESS 1 915 Commercial Street <br />SUBCONTRACTOR/CONSULTANT BSK Associates <br />crryisTATErzip Escondido, CA 92029 <br />PHONE 916-853-9293 <br />SUBCONTRACTORICONSULTANT ADDRESS 3140 Gold Camp Dr. #160 a-Nisi-ATE/zip Rancho Cordova CA 95670 <br />LICENSE X C-57 C-61 D-09 Other NUMBER 804318 EXPIRATION DATE 02/28/2022 <br />BILLING PARTY: OWNER CONTRACTOR x SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPUNG: . General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial <br />Public Water System <br />Water Quality Monitoring X Soil Sampling/Characterization <br /> <br />If different from Owner. Water System Name Contact Name or Phone Number <br />Push Point Other <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary x Auger Cable Tool <br />Gravel Pack/Gravel Size <br />ft <br />Plastic Stainless Steel Other <br />Sand Cement <br /> <br />Proposed Well Depth 15 ft Excavation 6-8 in diameter Open Bottom <br />Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel <br /> <br />Grout Seal Depth 15 ft x Neat Cement (94 lb bag/5-10 gal water) <br />Bentonite (20% solids) Other <br />Other Retardant / Accelerator (name) Grout Placement Method Pumped x Free Fall <br />ft Thick <br />PEDESTAL Other <br />ft Length in Christy Box Stove Pipe <br />Installed By Driller Pump Contractor <br />Concrete Pedestal Dimensions: Width <br />Pump Set ft Standing Water Level ft PUMP HP Submersible Turbine Other <br />TITLE Owner DATE 3/5/2021 <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 ,12....).a <br />sack mix/7 gal water <br />in diameter <br /> PA Yfin <br />13)Ce1/ 1141.1; <br />441/1R 2si 021 <br />Nop QU/N pivio6A ,20A/7. <br />u PA )-111.1:144 <br />Cd <br /> tItq <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE- STocKron CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgieM EXPIRES 1 YEAR FROM DATE ISSUED <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump Pump Replacement <br />Well Alteration/Modification Other <br />Soil Boring(s) # of borings X Geotechnical 2 #01 borings <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />Pump Repair Raise Well Casing <br /> <br />DEPARTMENT USE ONLY <br />Application Accepted By ..•.'---ZZ— Date 3/ it? 1 <br />Grout Inspection By 6.1,4 (i.: ft 8 iLly1.4", /44-vIL Date SI. it/2- q SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Check* <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Seryiga Request $, Invoice # Well ID# <br />43'701 1S0 4/9- ae4j -1- 4 6cie ;IP 01/00411(0 <br />i A <br />Area CA4/7. Employee ID# As <br />ft <br />'12_/76.37O WELL /PUMP PERMIT EHD 43-06 6/11/2019