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!' <br />B <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />nVI9-rc1=FUNUAt$Lt rtKMI I IAL LU`J %I04 -10V I FOR INSPECTION5 LAVIKtJ 9 TEAR FROM UATE ISSUED <br />JOB ADDRESS [611 N. (37.623909,-121.375696)] A` -R/ CITY/21P Tracy, CA 95377 <br />CROSS STREET 1-560 APN 25328003 PARCEL SIZE 181.6 ac LAND USE APPLICATION # <br />OWNER NAME San Francisco Public Utilities Commission PHONE 415-551-3000 <br />OWNER ADDRESS 525 Golden Gate Avenue CITY/STATE/LP San Francisco, CA 94102 <br />CONTRACTOR HEW Drilling PHONE 650-322-2851 <br />CONTRACTOR ADDRESS 1045 Weeks Street CITY/STATE/ jP East Palo Alto, CA 94303 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS CITY/STATE17JP <br />LICENSE N C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 604987 <br />PHONE <br />EXPIRATION DATE 10/31/2020 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) L7 Dibromochloropropane (4392) u Arsenic (4393) <br />INTENDED USE D DomesticlPrivate D Inigation/Agricultural F- Industrial D Water Quality Monitoring x Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well n Replacement Well D Well Alteration/Modification D Other <br />D Monitoring Well(s) # of wells Cl Soil Boring(s) # of borings Geotechnical 1 # of borings <br />D Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair <br />Drilling Method i Mud Rotary D Air Rotary ® Auger [i Cable Tool a Push Point D. Other <br />Proposed Well Depth 50 It Excavation up to 8 in. in diameter n Open Bottom D Gravel Pack/Gravel Size in diameter <br />CI Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad D Steel ❑ Plastic ❑ Stainless Steel D Other <br />Grout Seal Depth 50 it % Neat Cement (94 lb bag/5-10 gal water) D Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method X Pumped D Free Fall ❑ Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller D Pump Contractor D Other <br />Concrete Pedestal DDimensions: Width ft Length ft Thick in D Christy Box D Stove Pipe <br />PUMP L. Submersible❑ Turbine D 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 COMPENSATION LAWS. <br />MINIMUM 48 HOYR ADVANCE <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED - TITLE DATE <br />T <br />D <br />°o <br />A <br />N <br />N <br />P T M E N T U jA E C/N.1, 1 A <br />Application Accepted By Date Area _C� Employee ID# 1� <br />Grout Inspecti Date PECIAL Well Permit <br />Pump Inspectio y Date WAIVER Received <br />Soil Boring Inspec io B Date Constructed Well Depth ft <br />COMMENTS .z1 <br />'>��C�►,�1•��I/�L S11�1Q[�Til��Il+Zii�i�1L`��� <br />EHD 43-06 revised 4/14/18 <br />(>,/.' --If 8641/ i4.� IT <br />WELL /PUMP PERMIT <br />