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4 <br /> 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 /> JOB ADDRESS <br /> 18001 Commercial Street CITYIZIP Lathrop;95330 <br /> -f 7� D <br /> CROSS STREET Academy Drive APN PARCEL SIZE ! • L•ANO USE APPLICATION# a <br /> OWNER NAME Banta School District PHONE 209-229-4650 N <br /> OWNER ADDRESS <br /> 22345 El Rancho Road CITY/STATEfLP Tracy, CA 95304 <br /> CONTRACTOR GEO-Ex Subsurface Exploration PHONE 916-799-8198 <br /> CONTRACTOR ADORES$ 1510 Madera Drive CITY/STATE/ZIP Dixon, CA 95620 <br /> SUBCONTRACTOR ENGEO, Inc. PHONE 925-570-4056 <br /> SUBCONTRACTOR ADDRESS <br /> 17278 Golden Valley Parkway CITYISTATE/LP <br /> -- Lathrop, CA 95330 <br /> LICENSE XC-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomestidPnvale Irrigation/Agricultural Industrial Water Quality Monitoring XSoil Sarnpling/Characterization <br /> Public Water System <br /> If dilereni from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well -1:Well Alteration/Modification x Other CPT <br /> f Monitoring Well(s) #of wells LI Soil 80nng(s) a ei benngs Geotechnical 5 e of wnng5 <br /> J Out-Of-Service Well G Out-Of-Service Well Renewal Cross-Connection Repair <br /> --New Pump Pump Replacement !Pump Re air Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rota J Air Rotary ,Auger Cable Tool Push Point X Other CPT <br /> Proposed Well Depth It <br /> Excavation in diameter �Open Bottom Gravel Pack/Gravel Size in diameter <br /> Con ctor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter_in Thicknes Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth fteat Cement(94 1b bag/5-10 gal water : Sand Cement sacx mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped —i Free Fall X Other T rem i-e Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller Pump Contractor - Other <br /> Concrete Pedestal-Dimensions.Width R Length ft Thick in Christy Boa Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level It <br /> 1 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE r r llCJ�l'Y DATE -54? l 7 <br /> PAYMENT <br /> RECEIVE[) <br /> iAY 14 2019 <br /> N JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> -ArrPARTIM ENT U SjE O hit.Y <br /> Application Accepted By Date Area ' ployee ID#_�� <br /> Grout Inspection By Date PECIAL Well efmit <br /> PumpInspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> r <br /> PE SC Received Check#1 Amount Date Permit/ invoice# Well ID# <br /> Codes Info 8 ash Remitted Service RequestIL <br /> d I <br /> `c HC aT-06 rcmsN etan8 <br /> WELL!PUMP PERMIT <br />