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WELL/PUMP PERMIT <br /> SAN JDAOum COUNTY EuviRONMrNTAL HEALTH DEPARTMENT 1808EA3r HAZELT011AVEt1UE-STOCKTON CA 97209-0202(209)485-)420 <br /> NON-REFUNDABLE PERMIT www.s1gov.org1ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 650 W 10th Slre P-t Cnyrzl► Tracy.CA 95376 � <br /> CROSS STREET S Tracy Rlvd APN 23406013 PARCEL SIZE } LAND USE APPLICATION R <br /> OWNER NAME ._yy$cy—Uni Le-d-Schc)olyt,2U_cL-__. __._. PHONE 209-830-3200 N <br /> N <br /> OwNERADDRESS 1875 W Lowell Avenue _ crTYISTAtF/TJP Tracy. CA 95376 <br /> CONTRACTOR Middle Earth Geo Testing, Inc. ._ PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 N Lemon Street CRYISTATE/LP Orange,CA 92767 <br /> SVBCON7RACTORICONSULTANT RSK Associates p PHONE 916-853-9293 <br /> SUBCONTRACTORICONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CfTY1S7ATFmP Rancho Cordova,CA 95670 <br /> LICENSE XC-57 C-51 D-09 OD,or_ NUMBER 899451 ExPIRATIottDATE 06/30/2021....___ <br /> BILUNG PARTY: OWNER CONTRACTOR );SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General mineraliColiform Bacteria(4391) Dibromochloropropono(4392) Arsenic(4393) <br /> INTENDED USE Domestir,Priva!n IrngannnlAgtia.11urnl Industrial Water Oua6ty Nte000rxg X Sal S am pling'CharaCerizacon <br /> Pubic Water SySlem <br /> I!:,eennl+'cat O9.nc• — Vlebr,`.,rle'r Nry --_— - Cc.Tta:l N".aP'Kne Ni Z- r <br /> TYPE OF WORK New Well Replacement'.Vell Well Alteranon'IAOd1ficaa0n Other <br /> Mondonng Wells) i7 ofµ.IIs Sud Bormg(s) s I-Gcotedv¢al —s dW""' <br /> OutO!-SV"'CO Well Gut-Of-Service WEI Renewal Cross-Connacton Repa'r <br /> Now Pump Pump Replacement Punto Ropair_ Raise W'dl Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary As Rotary X Auger Catie Tool Push Point Othor <br /> Proposed Wall Depth 50 IT Escavatun 1.5 m dtameter Open Bolrcm Gra,el Pack/Gm el Sq. m ciamehrr <br /> Conductor Casing in ammeter I Conductor Caslrg Depth It <br /> Well Casing Diameter_In Thlckness'Gauge:ASTM Sched Steel Plastic Stainless Steel Otaer _ <br /> Grout Seal Depth 50 R X Neat Cement(94 1b bag5-10 gal Haler) Sand Cementsack mi 7 gal water <br /> Bentonite(20-A.scl.ds) Other <br /> Grout Placement Method Pumped Frce Fall a Diner CPT rods/Iremmie Retardant/Accelerator(nanw) <br /> PEDESTAL Installed By Drivar Pump Contractor OR,& <br /> Concrete Pedestal Dimensions Width R Length R Thick in Christy Box Stove Pipe <br /> PUMP Submersitlo Tudme Olhe+ HP Pump Set h Standing Water Level R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUN Y ORDINANCE STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND - WITH T CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPUANCE WITH ALL <br /> WORKERS COMX <br /> ION W <br /> (;t t NCE N E REQUIRED F MINS`PE'q'[I1OIV'-P 5E CALL/20')95/3-76:11 -t', <br /> SIGNED TITL 1��-I, fflATE L'L-4/LO 2-0 <br /> I <br /> I C MENT <br /> _ - - FI VED <br /> - <br /> 30 ?0?0 <br /> 4 4,ff EpMEtV7- TY <br /> R T MENT <br /> DEPARTMENT USE,ONLY <br /> ADplCahonAccepted By Dato 7 ,3U JriIU Area S /(•rIL EmployeelDid �k <br /> Grout Inspection By Data SPECIAL Well Permit <br /> Pump Inspection By / ! Date WAIVER Received <br /> Sod Boring Inspection By✓�'- {fData `� }•=C' Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received ('ChaNSl!!!_J Amount m <br /> Data PoriU Invoice M Woll IDM <br /> Codes Into Remltted Service Request Y <br /> t SG <br /> V.111 i`A PERIAI <br />