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t WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED is 172 Cn Trac CA 95377 JOB ADDRESS West Schulte Road (see map) CITY/ZIP y, m D CROSS STREET None L-c4 ITI p r$ APN 209-23X-030-966- PARCEL SIZE /"C) LAND USE APPLICATION# o m OWNER NAME City of Tracy PHONE_ 209)969-1524 N OWNER ADDRESS 333 Civic Center Drive CITY/STATE/ZIP Tracy, CA 95376 CONTRACTOR V&W Drilling PHONE (209)469-7700 CONTRACTOR ADDRESS 3806 Duck Creek Drive CITY/STATE/ZIP Stockton, CA 95215 SUBCONTRACTOR/CONSULTANT Klelnfelder Inc. PHONE (408)840-1038 SUBCONTRACTOR/CONSULTANT ADDRESS 380 North First Street, Suite A CITY/STATE/ZIP San Jose, CA 95112 LICENSE N C-57 LI C-61 LJ D-09 ❑ Other NUMBER 720904 EXPIRATION DATE April 30, 2020 BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE - Domestic/Private '.i Irrigation/Agricultural Industrial a Water Quality Monitoring X Soil Sampling/Characterization - Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK a New Well ❑ Replacement Well ❑ Well Alteration/Modification I_i Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings X Geotechnical 2 #of borings Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair ❑ New Pum ❑ Pump Replacement ❑ Pump Repair Raise Well Casing WELL CONSTRUCTION(NO WELLS ONLY GEOTECHNICAL BORINGS) Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 7 Push Point ❑ Other Proposed Well Depth 10 -S70 ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched _i Steel a Plastic ❑ Stainless Steel Other Grout Seal Depth i„?-SO ft 11 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water Bentonite(20%solids) �j Other Grout Placement Method A, Pumped C Free Fall a Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in a Christy Box ❑ Stove Pipe PUMP - Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MIN MUM=HR A OTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)953-7697 SIGNED TITLE Staff Professional -Kleinfelder Inc DATE 5/4/2020 lJ N O EL H VTAL DEPARTMENT USE ONLY /! Application Accepted By �� L Date S t/ z©zo Area S �C� Employee ID# y�+ Grout Inspection By Date H SPECIAL Well Permit Pump Inspection By Date I-1 WAIVER Received Soil Boring Inspection Byh1Lf.�,� Date 2,0 Constructed Well Depth ft COMMENTS PESC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 3 7� 150 C;C fi 0�5 S' W EHD 43-06 6/11/2019 /O�}y�� /��J��f WELL/PUMP PERMIT