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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT wWW.sjgov.org/encs EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 51 E Beverly PI CrrY/ZIP Tracy, CA 95376 <br />CROSS STREET Holly Drive APN 23333033 PARCEL SIZE 19!7 LAND USE APPLICATION # <br />OWNER NAME Tracy Unified School District PHONE_ 209-830-3200 <br />OWNER ADDRESS 1875 W Lowell Avenue CITY/STATE/zIP Tracy, CA 95376 <br />CONTRACTOR Middle Earth Geo Testing, Inc. PHONE 714-633-5025 <br />CONTRACTOR ADDRESS 954 N Lemon Street CITY/STATE/ZIP Orange, CA 92767 <br />SUBCONTRACTORICONSULTANT BSK Associates PHONE 916-853-9293 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr. #160 CITY/STATE/zip Rancho Cordova, CA 95670 <br />LICENSE X C-57 _ C-61 _ D-09 _ Other NUMBER 899451 EXPIRATION DATE 6 3V3 <br />BILLING PARTY: _ OWNER _ CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <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 />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />_ Monitoring Well(s) # of wells _ Soil Boring(s) # of borings X Geotechnical _2 _# of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair .. Raise Well Casing <br />f WELL CONSTRUCTION <br />I Drilling Method _ Mud Rotary _ Air Rotary X Auger _ Cable Tool _ Push Point _ Other <br />Proposed Well Depth 50 ft 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 lb bag/5-10 gal water) _ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall X Other CPT rods/trefT mie Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />_ Concrete Pedestal _Dimensions: Width ft Length ftThick in _ Christy Box _ Stove Pipe <br />iPuMP _ Submersible_ Turbine _ 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 <br />STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE I THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSAAON OWS. <br />MINIMUM 48 E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />( <br />SIGNED TITLE ` C `� DATE 01/17/2022 <br />T <br />-i <br />m <br />D <br />0 <br />0 <br />m <br />m <br />N <br />y <br />0 <br />DEPARTMENT USE ONLY <br />Application Accepted By ji L— Date /.7. <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By rlj- Date 2 <br />COMMENTS <br />Arearc,ct Employee ID# <br />E SPECIAL Well Permit <br />I i WAIVER Received <br />Constructed Well Depth <br />m <br />PE SC Received Check#/ <br />Codes Info B Ca h <br />Amount <br />Remitted <br />Permit! <br />Dat Service Re nest # Invoice # Well ID# <br />EHD 43-06 6/11/2019 ( / , 130.4 - <br />TOO WELL/PUMP PERMIT <br />