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ihfELl.iP1!f1 P KiRWI <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HALLLION AVENUE-STOCKTON CA 95205 - (203) 468-3420 <br />MUIY-111EFUNUAt1Lt rtKMI1 1..ALL JLU.7/ JOS-/OUf FUK IN5Ytl:TIUNS CArIKr.0 'I TtAK FKUM UAIt 15JUtU <br />JOS ADDRESS 29559 S. Bird Rd. <br />cmvlTUP Tracy, 95304 <br />CROSS STREET Lehman Rd. APN <br />253-330-30 PARCEL SIzE _07 LAND UBE APPLICATION III <br />OWNER NAME American T� A.4 -r— <br />10 Presidential Way /t <br />&, A)MA.// PHONE 781-926-4500 W <br />OWNERADDRESS 947 <br />4 a -k CITYISTATE/ZIP Woburn, MA. 01801 <br />CONTRACTOR Moore TWinina Associates, Inc. <br />PHONE 559-288-7021 ■ ■W■ <br />CONTRACTOR ADDRESS 2527 Fresno St. <br />CITY/STATE/zip Fresno, CA. 93721 <br />SUBCONTRACTOR <br />PHONE le <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 C-61 Ci D-09 ❑ <br />CITY/STATE/ZIP <br />NUMBER 506159 EXPIRATION DATE 2-26-2019 <br />DOMESTIC WELL SAMPLING: r General Mineral/Coliform Bacteria (4391) 1; Dibromochloropropane (4392) C; Arsenic (4393) <br />WENDED USE ❑ Domestic/Private C Irrigation/Agricultural n Industrial a 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 '_ Now Well ', Replacement Well a Well Alteration/Modification Cl Other <br />Monitoring Weli(s) # of wells U Soil Boring(s) s or bodnaa X Geotechnical 1 a of bodnSa <br />11 Out -Of -Service Well D Out -Of -Service Well Renewal G Crusa-Connection Repair <br />B <br />as <br />Drilling Method iXMud Rotary a Air Rotary IX Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Wall Depth 60 It Excavation 6" in diameter ❑ Open Bottom 17 Gravel Pack/Gravel Size _ in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth tt <br />Wall Casing Diameter in ThickneS /Gauge/ASTM Schad D Steel 11 Plastic D Stainless Steel n Other <br />Grout Seal Depth�ftNeat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) '❑ ther <br />Grout Placement Method X Pumped ❑ Free Fall ❑ Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By U Driller 11 Pump Contractor ❑ Other <br />is Concrete Pedestal oDlmenslons: Width It Length It Thick in ❑ Christy Box ❑ Stove Pips <br />PUMP _ :l Submersible n Turbine 0 Other HP Pump Set ft Standing Water Level j 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 />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />NCE NOTICE REQUIRED FOR <br />� INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE{[►1(�1A1� UY/.L✓✓'t DATE <br />M E N T�U�L <br />Dale "7�F _�4 <br />Date �T <br />Date <br />Data <br />5.i <br />S <br />N <br />r <br />Aroa__ EmployeeID#� <br />5 SP CIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />EHD 43-e0 t4vlaed 4(14/18 WELL /PUMP PERMIT <br />FA <br />= U <br />W <br />W <br />0 I <br />Wa <br />Z <br />Lf <br />