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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUIV-IM"IL ACLt rt:KMI I t -KILL (LUU) U04 -10J/ FUK IN5PtG IIUNS tAYIKCJ "1 TtAK I-KUM UAIt 155UtU <br />ADDRESS 17950 Via Nicolo Road <br />CITYlZZIP Tracy, 95377 <br />SS STREET Patterson Pass Road APN 20911006 <br />PARCEL SIZE"` )LAND USE APPLICATION # <br />IER NAME Musca Family Olive Company <br />PHONE (209) 229-7055 <br />IER ADDRESS 17950 Via Nicolo Road <br />CITY/STATE/ZIP Tracy, CA 95377 <br />TRACTOR Terraphase Engineering Inc. <br />PHONE (510) 645-1850 x48 <br />TRACTOR ADDRESS 1404 Franklin Street <br />CITY/STATE/ZIP Oakland, CA 94612 <br />CONTRACTOR California Push Technologies Inc. <br />PHONE (510) 357-3677 <br />-ONTRACTOR ADDRESS 820 Aladdin Avenue <br />CITY/STATE/ZIP San Leandro, CA 94577 <br />NSE X C-57 C-61 0-09 - Other <br />NUMBER 884827 EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE - Domestic/Private - Irrigation/Agricultural - Industrial - Water Quality Monitoring X Soil Sampling/Charactedzation(Geotechni <br />- Public Water System Chris Janes (860) 989-8538 <br />If different from Owner Water system Name Contact Name or Phone um r <br />TYPE OF WORK - New Well - Replacement Well - Well Alteration/Modification - Other <br />- MonitoringWell(s) #of wells - SoilBoring(s) #of borings X Geotechnical 5 #ofborings <br />- Out -Of -Service Well - Out -Of -Service Well Renewal - Cross -Connection Repair <br />New Hump vump Ke lacemenr vump Ke air Kaise Well Lasing <br />WELL CONSTRUCTION <br />Drilling Method - Mud Rotary - Air Rotary - Auger - Cable Tool X Push Point - Other <br />Proposed Well Depth ft Excavation 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 Sched - Steel - Plastic Stainless Steel - Other <br />Grout Seal Depth 70 It X Neat Cement (94 /b bag/5-10 gal water) - Sand Cement sack mixf7 gal water <br />- Bentonite (20% solids) - Other <br />Grout Placement Method - Pumped - Free Fall X Other Tremie Piped - 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 />MINIMUM 24 HpO�UR P VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 4o---�t.n, D Raw- TITLE President, PG DATE 09/21/2017 <br />EIVED <br />2 5 2011 <br />AL HEALTH <br />RVICES <br />` r <br />Area `� ' 1 Employee ID#hM <br />E SPECIAL Well Permit <br />L WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received <br />Info B <br />eck#O <br />Amount Date <br />Remitted <br />Permit/ Invoice# WellID# <br />Service Re uest # <br />qs7 <br />is <br />0.�1yt� <br />EHD 43-06 WELL/PUMP PERMIT <br />4/30/12 <br />