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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS [620N,(37.623531,-121.391648)] CITy/ZIP Tracy,CA 95377 m <br /> -580 21121 ae D <br /> CROSS STREET APN 26506005 PARCEL 512E LAND USE APPLICATION# z <br /> m <br /> OWNER NAME San Francisca Public Utilities Commission PHONE 415-551-3000 u <br /> OWNER ADDRESS 525 Golden Gate Avenue CITYISTATE/ZIP San Francisco,CA 94102 <br /> CONTRACTOR HEW Drilling PHONE 650-322-2851 <br /> CONTRACTOR ADDRESS 1045 Weeks Street CITYISTATEIZIP East Palo Alto,CA 94303 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE x C-57 C-61 D-09 Other NUMBER 604987 EXPIRATION DATE 10/31/2020 <br /> DOMESTIC WELL SAMPLING:i I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)Li Arsenic(4393) <br /> INTENDED USE n Domestic/Private i-.Irrigation/Agricultural -1 Industrial i i 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 /> TYPE OF WORK -New Well Replacement Well Well Alleration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) #of borings x Geotechnical #of borings <br /> Out-Of-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement a Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary x Auger I i Cable Tool i i Push Point 11 Other <br /> Proposed Well Depth 50 ft Excavation up to 8 in.in diameter Open Bottom i Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <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/610 gal water) Sand Cement sack mixt/gal water <br /> Bentonite(20%solids) I Other <br /> Grout Placement Method x Pumped n Free Fall I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller I.'.Pump Contractor r; Other <br /> I Concrete Pedestal Dimensions:Width ft Length ft Thick in ri Christy Box Stove Pipe <br /> PUMP Submersible Turbine i-Other HP Pump Set ft 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 COMPENSATION LAWS. <br /> MINI M 4l HOUR,fDV��TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 77�1j1{{.( 4`!"�fY TITLE DATE <br /> O <br /> ?,0/ <br /> � O <br /> FNT <br /> D�AR MNT U E 7NLY <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> odes Info 91M.. Qash Remitted Service Re es # <br /> '1 <br /> EHD 43-06 revised 4114/18 1XI WELL/PUMP PERMIT <br />