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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EASTHAZELTON AVENUE - STOCKTON CA 95205 - 12091 AGS -3421 <br />NVN-KEFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />,JOB ADDRESS 1611 N. (37.623909. -121.375696)] CITYIZIP Tracy, CA 95377 <br />CROSS STREET 1-580 25328003 <br />APN PARCEL SEE 7816 ac LAND USE APPLICATION # <br />OWNER NAME San Francisco Public Utilities Commission-551PHONE 415-3000 <br />OWNER ADDRESS 525 Golden Gate Avenue CITY/STATE2fP San Francisco, CA 94102 <br />CONTRACTOR HEW Drilling <br />PHONE 650322-2851 <br />CONTRACTOR ADDRESS 1045 Weeks Street CITY/STATTJ7J, Fast Palo Alto, CA 94303 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEf7JP <br />LICENSE X C-57 1 C-61 D-09 f. Othef NUMBER 604987 EXPIRATION DATE 10/31/2020 <br />UOMES'IC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) L DibromOChlorODrODane (4397) _I Arsenir 143n31 <br />NTENDEO USE -. U0meStiC/Pr1V8te L Irrigation/Agricukural Industrial t i Water Quality Monitoring X Sod Sampling/Characterization <br />E PUTAC Water System <br />It erlerent from Owner: Water System Name COMad Name ar Phone Number <br />...ay. vvcn mupld-Tient vvea vvell AnefatlONiviocimcabon : Other <br />"MonitoringWell(s) #of woos SoilBoring(s) #o(benr'gs Ix Geotechnical 1 #olbenngs <br />Out -Of -Service Well Out -Of -Service Well Renewal I Cross•Connectron Repair <br />New Pump Pump Replacement Pump Repair t Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point , Other <br />Proposed Wen Depth 50 ft Excavation Up to 8 in. in diameter r Open Bottom U Gravel Pack/Gravel Size_ in diameter <br />Li Conductor Casing in diameter / Conductor Casing Depth R <br />Well Casing Diameter in Thickness/GaugeIASTM Sched :, Steel Plastic I. Stainless Steel Other <br />Grout Seal Depth 50Y ft W Neat Cement (941b bag/5-10 gal water) Sand Cement sack mWx/7 gal water <br />I Sentonde (20% solids) : Other <br />.Grout Placement Method R Pumped 7 Free Fall I i Other :I Retardant 1 Accelerator (name) <br />PEDESTAL Installed By --I <br />Driller , Pump Contractor Other <br />-1 Concrete Pedestal i IDimenslons: Width ft Length ft Thick in i i Christy Box I. Stove Pipe <br />PUN, L Submersibles, Turbine :- Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE-P4REPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN.:LOUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AMb`A6jjVE WITH THE CAkjFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORK l S COMPE AVON LAWS I <br />I I � I �` h _ l r { - i - PLEASE CALL (209) 953-7697 <br />SIGNED',rteli� i:.... r L'e:�. - C �_ <br />r TITLEVr:. DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspec on By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date Area Employee ID# <br />Date 1; SPECIAL Well Permit <br />Date J WAIVER Received <br />Date Constructed Well Depth ft <br />PE <br />Codes <br />SC Received <br />Info BY <br />Check#1 <br />Cash <br />Amount <br />Remitted Date <br />Permit/ <br />Service Re uesl# Invoice III WellID# <br />WELL /PUMP PERMIT <br />IOM <br />a <br />