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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CAS5205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> f/1 <br /> JOB ADDRESS 300 E Legacy Dr. (Wicklund ES) crry/LP Tracy, CA 95376 <br /> CROSS STREET S Providence Street APN 25404004 PARCEL SIZE ISIZIaLAND USE APPLICATION# <br /> m <br /> OWNER NAME Lammersville Unified School District PHONE (209) 836-7400 N <br /> OWNER ADDRESS 111 De Anza Blvd. crryisTATE2IP Tracy,CA 95391 <br /> CONTRACTOR Baia Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street cnY/sTATEmp Escondido, CA 92029 <br /> SUBCONTRACTORICONSULTANT RSK Associates PHONE 916-853-9293 <br /> SUBCONTRADTORICONSULTANTADDREss3140 Gold Camp Dr.#160 cir,rlsTATEmp Rancho Cordova,CA 95670 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 804318 EXPIRATION DATE 02/28/2022 <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 Omer. 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�_ 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 /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 15 ft Excavation 6-8 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 Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 15 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 x Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP 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, 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 /> MIINIMUM.J8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED /i..J�f�af' TITLE Ower DATE 12/29/2020 <br /> Ec MFNr <br /> EI QED <br /> C 3 ?�20 <br /> H 01V cjou <br /> EPq RTMFNT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date I a �nO�d Area R�7 Employee ID# /t <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection:By Date C nstructe Well Depth ft <br /> COMMENTS�T i9111IP 4z ho r"�fL�' f �f�U W''I L /S �17(:aL rtfe7 <br /> PE SC Received Chedal Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cie.h Remitted Service Request# <br /> 9PI2 !9T, w <br /> EH043-O6 6111/2019 //`���� WELL/PUMP PERMIT <br />