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I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 t NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS vZ SO 1J- Kc4v a yu, 411.-- -C) Hes gadero rArk CITY/ZIP Tracy / 95376 CROSS STREET Parker Avenue APN 21450001 PARCEL SIZE j 16 LAND USE APPLICATION # OWNER NAME City of Tracy PHONE 209-831-6000 OWNER ADDRESS 333 Civic Center Plaza CITY/STATE/ZIP Tracy, CA 95376 CONTRACTOR Taber Drilling PHONE 916-371-8234 CONTRACTOR ADDRESS 536 Galveston Street CITY/STATE/ZIP West Sacramento, CA 95691 SUBCONTRACTOR BSK Associates PHONE 209-245-0492 SUBCONTRACTOR ADDRESS 252 W Larch Rd, Suite 252-H CITY/STATE/ZIP Tracy, CA 95304 LICENSE ❑ G5 ❑ C-61 ❑ D-09 ❑ Other NUMBER 969927 EXPIRATION DATE 2/29/2024 DoMEsnc WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) u Arsenic 4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring <5 Soil Sampling/Characterization ❑ Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification Other CPTs - total of 2 # of borings f n ❑Monitoring Well(s) # of wells Soil Boring(s) 4 Geotechnical �E A, ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair �V' V ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION UG 3 Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point � Other CPTS Z�j7 Proposed Well Depth 15 t0 100 ft Excavation t0 6 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size��.,C.�Ao /ro diameter C Conductor Casing in diameter I Conductor Casing Depth ft MEAL- �T ON Cot Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other CEPA NTAL Grout Seal Depth 15-100 ft eat Cement (94 Ib baq/5-10 gal wa ❑ Sand Cement sack mix/7 gal ❑ Bentonite (20% solids) ❑ Other Capped with rapid set concrete 'in paved areas Grout Placement Method ❑ Pumped Free —FaTD <t e Tremie ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick �in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY r - Application Accepted By G� G� Date 9A I ;?a Area kl-nnxv Employee D#_& Grout Inspection By Date ❑ SPECIA Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By t Date q1 I Z I 1-Z Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount DaPermit/ Invoice # Well ID# e Codes Info B Cash Remitted Service Request # So 1 2 EHDO43-0604/07/2022 �!&n Page I of2 Well / Pump Permit T m D 0 A m y