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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH r QTMENT 304 E WEBEI 3a"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT /- kPIRES 1 YEAR FROM DATE ISSUED W tP -t JOB ADDRESS t -L� crfv�zlP TRACY 95736 J� ; CROSS STREET �_-t * "y 4 APN235—I50• �W . PARCEL SIZE'?.5yACRESI N OWNER NAME UNION PACIFIC RAILROAD CO. PHONE (402) 544-8600 OWNER ADDRESS 1400 DOUGLAS STREET CITY/STATE/ZIP 014AHA, NE 68179 C it*eTw GEOCON CONSULTANTS, INC. PHONE (916) 852-9118 CA.;rvt*e:P@RADDRESS 3160 GOLD VALLEY DRIVE, SUITE 800 CITY/STATE/ZIP RANCHO CORDOVA, CA 95742 411199EONTRAcTOR VIRONEX, INC. PHONE (510) 568-7676 *WCONTRACTOR ADDRESS 2110 ADAPTS AVENUE CITY/STATE/ZIP SAN LEANDRO, CA 94577 LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 7()5927 EXPIRATION DATE 5111/09 GEOGRAPHICAL INFORMATION: Coordinates x 37°44'04"N Y 121*99139191— Township _5_ Range_5Z_ Section_2B INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ,_F_]Water Quality Monitoring j7 Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) number of wells Z Soil Boring(s) 8 number of borings ❑Geotechnical number of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION NO WELL CONSTRUCTION—BORINGS ONLY Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Toot XI Push Point ❑Other Proposed Well Depth 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 11Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft Neat Cement(94 lb hug 15-10 gal water) ❑Sand Cement suck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other NOT APPLICABLE — NO WELLS ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ti Standing Water Level ft WELL DESTRUCTION N/A ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb bag/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. - MI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE SENIOR GEOLOGIST DATE 11/19/04 DEPARTMENT USE ONLY Application Accepted By. Date It Area Employee ID# ga Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By /Date Constructed Well Depth - ft COMMENTS Ste? �� J �Sn (.()c (D� <S r�P UC_��e v�+�7 91 r lXTlyir4� PE SC Amount Check#/ Received Date Permit/ Ili oice# Well ID# Codes Infu Remitted Cash By Service Request# 6 EHD 43-02-006 MASI'FR WATER WELL PERMIT 5/7/2002