Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAOUlN COUNTY ENv1aowwwAL HEALTH DEPARTMENT 1 M EAST HAZ[LToN AvENult-STOCNTON CA 95205-6232(209)4ha-3420 <br /> NON-REFUNDABLE PERMIT www.sigoV orglohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS )37c> N, PGirker OZJv - k A CrTYmr <br /> CROSS STREET Parker Avenue APN 23314028 PARCEL SIZE S,I1!J LAND USE APPLICAnON s <br /> OWNER NAME Tracy Unified School District PHONE 209-830-3200 C <br /> OWNER ADDRESS 1875 W Lowell Avenue crrYISTATEmp Tracy,CA 95376 <br /> CONTRACTOR Middle Earth Geo Testing Inc_ Pow 714-633-5025 <br /> CONTRACTOR ADDRESS -954,.N Lemon Street Crr/STATEm►Orange, CA 92767 <br /> SuecowitAcToaCoNsutt"T HSK Associates PHONE 916-853-9293 <br /> SUEICONTRACTOR/CONSULTAHT ADDRESS 3140 Gold Camp Dr._#160 CrTY;STAtEIZW Rancho Cordova,CA 95670 <br /> UcEN$E xC-5? C-. 0-09 Clner NUMBER 899451 E%rlRAnoNDArE Wj QjM.1 <br /> BILLING PA/rY: OwNett CONTRACTOR X SUBCONTRAC7OR/CON9U1.TANr <br /> DOMESTIc WELL SAMPLING: General Mineral/Coliform Bacteria(4391, Dibrornochloropropane(4392) Arsenic(4393) <br /> INTENDEDust Dcmestic'Pnvate Imgaaon'Agricultural Industrial Ovality Monitoring X Sod Sampling:Charactenzation <br /> PjotC Water System <br /> n co—m tom Dwa1 'Naar$nwn Har+ Coelad Hart a Pharr Mnrew <br /> TrPE OE WARN New Wee Replacement'Nell 'Wall ARaratno V1,1 rT"n Other <br /> NIOnTenng Wei,sr x or wens Sod Bonngt e) a y-,, X Geotachn�cal of camps <br /> out-0r-Serv,ce Weil Out-Ot-Senrrw Wee Renewal Cross-Connecwn Recaa <br /> New Punic Pump R ace.nent Pump R +r Raise Well Caair <br /> WELL CONSTRUCTION <br /> Dnlung Method Mud Rotary A.r Rosary :t Auger Cade Toot Pusn Pont Omer <br /> Proposed Well Depen 50 R Exravawn 1_5 in aametor Open Bottom Gravel PaduGravel Size �n dartMer <br /> Conouctor Casing in memeter I Conductor Casing Deom it <br /> Well Casing Diameter_n Tna*riass'GarpNASTM Schad Steel Ptasw Stainless Sleet other <br /> Grout Seal Depm 50 IT %Nee:Carrion:(94 lb DoWS.TO gat eaten Sano Cemem sacA rn-7 gal water <br /> Bentonite(20%sola.) Omer <br /> Grout Placement Method Pumped Fran Fall it other CP-r rod3/lfBfTrlle Retardant I Accelerator(ramp) <br /> PEDESTAL Instai By Driller Pump Contractor Otrer <br /> Concrete Pedestal Dlrrwalons Width R Length R Thick m Christy Box Stove Pipe <br /> PMP Submersible Twt-e Olney HP _ Primp 'I Stnrdmg Waver Level R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED TMS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATELIS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> W <br /> CURRENT AND ACTIV nN THE CAF NlA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS C PENSA N LAWS. <br /> UR AD NCE NOTICE REQUIRED FQRIINSPECTIPN13.11 PLEAWCA�LLAln0g)953-7697 <br /> TITLE E <br /> r- <br /> G <br /> 30 Z420 <br /> O <br /> - <br /> pgRNI A--L lit H <br /> TY <br /> r <br /> DEPARTMENT USE QNLY <br /> r_�zz 7 30 <br /> ApplaetWn Accepted By Date _ enplcyee lDe <br /> Grout Inspector By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Sod Boring Inspection By Data Constructed Well Depth R <br /> COMMENTS <br /> PE SC Cody kft Rep 116- Remitted Deb Servlcs R r wet 0 Invoice tj I Well IDI <br /> 7 SO <br /> "0411 6,,1,7111E wILL eUMPPEPUT <br />