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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCNTON CA 95205-6232(209)468.3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 535 Mabel Josejlt p Drive _-. - _- cirriz1P Tracy, CA 95ZL-__. <br /> CROSS STREET Rla Gt(CtDnP Drl�ytee,.�^^� r�A�PIN 24007016 —PARCEL SIZE LAND USE APPLICATION a <br /> OWNER NAME .Tracy Unified-ScLool District PHONE 209-830-3200 <br /> OWNER ADDRESS 1875 W Lowell Avenue CITY'STATE/ZiP Tracy: CA 95376 <br /> CONTRACTOR Middle Earth Geo Testinq, Inc.__ PHONE 714-633-5025 <br /> CONTRACTORADORESS 954 N Lemon Street - CtTY1STATE,ZJP-0range, CA 92767 <br /> SUBCONTRACTORICONSULTANT 8SK Associates PHONE 916-853-9293 <br /> SUBCONTRACTORICONSULTANT ADDRESS 3140 Gold Camp Dr.#160__ CrTYlSTATTJLPf_�ancho Cordova, CA 95670 <br /> LICENSE x C-57 C-61 D-09 Otn-fNUMBER 899451 EXPIRATION DATE 06/3012021_ <br /> &LUNG PARTY: OWNER CONTRACTOR j( SUBCONTRACTOR/CONSULTANT <br /> DOMEST1c WELLSAwPuNG: General IUineral/Wifono Bactena(4391) Dibromochloroproparle(4392) Arsenic(4393) <br /> INTENDED USE OomestR:Private Imgation/Agricultural Industrial Water Quality MomturvV X Sol]SampGng.Characteriza9on <br /> Pubbc Water System <br /> X dONniM rrem r?win• Willer Sysiem Nsme C-L-!N—or Friona Number <br /> TYPE OF WORK New Well Replacemenl'Nell Well AheratiorvVioCrfcatlon Other <br /> Monitoring Wellrsi 0 of welts Sod Bonng(s) sir oannge x Geotechnical <br /> Out-Of-Service Weil Out-O(-Service Well Renewal Cross-Connecnon Ropan <br /> New Pump Pump Replacement Pump Repair Raise Well Casrn <br /> WELL CONSTRUCTKIN <br /> Drilling Method Mud Rotary Arc Rotary X Auger CaDTe Tool Push PGn( Other <br /> Proposed Well Depth 50 R Excavation 1.5 in diameter Open Bottom Gravel Pac$vGravel Sae In diameter <br /> Conductor Casing In diameter / Conductor Casing Depth N <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 h X Neat Cement(94 M oag15-10 gal water) Sand Cement sack mixi7 gat water <br /> Eem:rine(20%solids) Other <br /> Grout Placement Method Pumped Fres,Fall x over CPT rods/tremmie Retardant r Acceloril(Mme) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> ConersU Pedestal Dlmsnalone'Wkith h Length R ThPck m Christy Bos Stow Pipe <br /> Pum. SubmeroVble Turtnne Other HP Pump Set R Standing Water Levet It <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIN COUKrY QRDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND, E H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP S T� WS. <br /> ` ADVANCE NOTICE REQUIRED F SPECTI S-FLE,0442E CALL 1409)9533-1(6,97 <br /> SIGNED TITLE ^^'1 y i <br /> Pq yM� <br /> 3 0 D <br /> ?020 <br /> l D�W�NQ ANT Y <br /> RTMFNT <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By Date //,-i� 1701, Area v/ Employee 106 <br /> Grout Inspection By. Date ZZY-0/2 <br /> Well Permit <br /> Pump Inspection By--��—� Dale WAIVER Received <br /> Soil Boring Inspection By .to_ Constructed Well Depth __ M <br /> COMMENTS <br /> PE Sc Recelvsd —�—Checkjlffoil AmeMM Dass Permit/ Invoices Well IDs <br /> Casks 111111111 _ <br /> CaRaa1Md Servs 11est e <br /> ' 37 IS'b _. ---I _--- <br /> EH1)43,015 11,11201111, _. ---_.. :d t: FUrwp<PI.nT <br />