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WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH r `RTMENT 304 E WEBEP ^•.3°"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT .PIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS _ � 8 SG�� CITY/ZIP TRACY 95736 y 'r D'3�-ACRES¢.V CROSS STREET Cr V APN235-150. 40 ,-'06 t;0�Z,3 PARCEL SIZE '3r 5 ( 4- )��A5 OWNER NAME UNION PACI IC RAILROAD CO. PHONE (402) 544-8600 OWNER ADDRESS 1400 DOUGLAS STREET CITY/S'T'ATE/ZIT' Dj4AAA, NE 6817 C.0^5V'[40^A_GEOCON CONSULTANTS, INC. E� PIIONE (916) 852-9118 G0 nSa(-}urs-- G@?a,itAc=F9RADDRESS 3160 GOLD VALLEY DRIVE, SUITE 800 CITY/STATE/ZIP RANCHO CORDOVA, CA 95742 .&MCONTRACTOR VIRONEX, INC. PHONE(510) 568-7676 $COCONTRACTOR ADDRESS 2110 ADA14S AVENUE CITY/STATE/ZIP_,SAN LEANDRO, CA 94577 LICENSE R C-57 ❑C-61 ❑D-09 ❑Other NUMBER 705927 EXPIRATION DATE GEOGRAPIIICAL INFORMATION: Coordinates x 3-1644104"M Y 1210 .5'35"W Township _2,5_ Range _ Section-2L_ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial Ski Water Quality Monitoring k Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact amt or one, um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofo0 Soil Boring(s) 8 ❑Geotechnical ells numberofborings 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 Tool Xl 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 Il 1 Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft Neat Cement(94 1b hag/5-10gal water) ❑Sand Cement suck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on Filt ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other NOT APPLICABLE — NO TATELLS ❑Concrete Pedestal Dimensions: Width ti Length ft Thick in ❑Christy Box ❑Stove Pipe PUNIP ❑Submersible ❑Turbine ❑Other HP Pump Set ti Standing Water Level tt WELL DESTRUCTION N/A ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ti Depth to Water tt ❑Casing to be Pertorated from tl to ft Sealing Material ❑Neat Cement(94 lb bag/5-10gal it-tiler) ❑Sand Cement sack tnis/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 ti 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. ' MI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE_ SENIOR GEOLOGIST DATE 11/19/04 ✓yam DEPARTMENT USE ONLY Application Accepted By ,'l ' Date t' T Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date C nstruc�+ed Well Depth L ft COMMENTS ,St U rL�� i `� "t;-1) (�) �o S�r�c�-� fiD �0 C a �— t�r'ou tl L ✓t S PE Sc Amount Check#/ Received Permit/ Codes Info Remitted Cash gy Date Service Request# Invoice# Well ID# z t3 q 5 EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/2002