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JOB ADDRESS <br />CROSS STREET APN 23860007 PARCEL SIZE 3.00 Actroto USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />F & F Tracy Partners LLC <br /> <br />PHONE <br /> <br />7890 Delta Avenue, Tracy CA 95304. CITY/STATE/ZIP <br /> <br />Terracon Consultants, Inc <br /> <br />PHONE 925.609.7224 <br />3140 West Grant Line Road crryalp Tracy, 95304 <br />South Lammers Road <br />CONTRACTOR ADDRESS 1220 Concord Avenue Suite 450 CITY/STATE/ZIP Concord CA 94520 <br />SUBCONTRACTOR Neil 0. Anderson & Associates DBA Terracon Consultants, Inc PHONE 913.599.6886 <br /> <br />SUBCONTRACTOR ADDRESS 10841 S Ridgeview Road <br /> <br />CITY/STATE/ZIP Olathe, KS 66061 <br /> <br />LICENSE KC-57 0 C-61 0 D-09 0 Other NUMBER 669004 EXPIRATION DATE 05/31/2023 <br />DOMESTIC WELL SAMPLING: U] General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) H Arsenic (4393) <br />INTENDED USE U Domestic,/Private U Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well <br />Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings OCGeotechnical 5 _ # of borings <br />Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />Submersible 0 Turbine U Other PUMP HP ft Standing Water Level ft Pump Set <br />ft Excavation in diameter 0 Open <br />Mud Rotary <br />Depth <br />Drilling Method <br />Proposed Well <br />ft Thick <br />PEDESTAL <br />in <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Installed By 0 Driller 0 Pump Contractor 0 Other <br />Concrete Pedestal 0Dimensions: Width ft Length <br />Christy Box 0 Stove Pipe <br />WELL CONSTRUCTION <br />Conductor Casing in diameter / Conductor Casing Depth <br />Diameter in Thickness/Gauge/ASTM Sched 0 Steel <br />Depth /.. ft / Neat Cement (94 lb bag/5-10 gal water) <br />Bentonite (20% solids) 0 Other_________________ <br />Grout Placement Method 0 Pumped 0 Free Fall .Wr'Otl---4'('IC—,vYO•*J 0 Retardant / Accelerator (name <br />Well Casing <br />Grout Seal <br />ft <br />Plastic 0 Stainless SEVEMFeNT <br />Sand Cement RECEIVEI3- ixI7 gal water <br />0 Air Rotary 0 Auger 0 Cable Tool U Push Point U Other <br />Bottom 0 Gravel Pack/Gravel Size in diameter <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />NIININIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Application Accepted By <br />DEPARTMENT <br />Date <br />U E ONLY <br />/ ZZ Are6 ravk Employee ID# <br />Grout Inspection By Date CI SPECIAL Well Permit <br />Pump Inspection By Date II WAIVER Received <br />Soil Boring Inspection By • Date lo I 14 I 7dt Constructed Well Depth ft <br />COMMENTS 3 bor,15 oaf- 25 r 5 b•riAis Ai- 3 <br />0 Well Alteration/Modification 0 Other <br />1 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 />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />if3.7 2 /50 C reAlif 47€30 0.1' •22. WebOq3q 19- r <br />Cold # 15-/3/ '7527 <br />1 ofi q (22" :SSMICICIV 311S EHD043-06 04/07/2022 Page I of 2 Well / Pump Permit