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it <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />nvn-rtEFUINUAI3LE VERMIT —www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS --2B75 Holl/ Drive. <br />CITY/ZIP Tracy CA 85376 <br />CROSS STREET. Kavanagh Avenue APN 21450002 <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME Tracy Unified School District <br />PHONE 209-830-3200 <br />OWNER ADDRESS 1875 W Lowell Avenue <br />CITYISTATE/ZIP _Tracy, CA 95376 <br />CONTRACTOR Middle Earth Geo Testing Inc <br />PHONE 714-633-5025 <br />CONTRACTOR ADDRESS 954 N Lemon Street <br />CITY/STATE/ZIP Orange, CA 92767 <br />SUBCONTRACTOR/CONSULTANT BSK Associates <br />PHONE _ 916-853-9293 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp <br />Dr. #160 CIN/STATE/ZIP Rancho Cordova CA 95670 <br />LICENSE X C-57 C-61 D-09 Other <br />NUMBER 8994_ EXPIRATION DATE <br />BILLING PARTY: OWNER CONTRACTOR <br />X SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) DibromochloroDrooane (43921 Arsenic (4.s4rt) <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 System Name Contact Name or Phone Number <br />- - ••-^^ ­y'r ... m ' v I, vveu AneranontMDGrticaoon Uther <br />Monitoring Well(s)9 of wells Soil Boring(s) # of borings X Geotechnical _�_4 or ric-9s <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 50 If 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 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall X Other CPT rods/tremmle Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length A 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 CO TION LAWS. <br />.11N1 1,10 4 UR DVANC ICE REQUIRED FO//((((������'' INSPECTI S - LEAS��y(IAL.��jjL (200x9) 953-76 7 <br />SIGNED - TITLE Z1C[ M l �'Ns - L ' /C(,r Q'/j}(.' L / e;q <br />DEPARTMENT USE(�O LY _ <br />Application Accepted By _��/�'�— L- Date Area `' �r--1 i Employee ID# C <br />Grout Inspection By 1'� . �'1��, Date L� SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />(A <br />m <br />D <br />N <br />RE yMF <br />cF/W or <br />SEP <br />8,70 <br />�q QU?1 <br />'ROA/IN CC) <br />WELL !PUMP PERMIT <br />Li�►iii:���t��►�►���s�l���fn����,ru_ <br />WELL !PUMP PERMIT <br />