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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 16555 Von Soct .n Road (Bethany) cITY/ZIP Tracy. CA 95304 m <br /> D <br /> CROSS STREET Hansen Road APN 20914009 PARCEL SIZE - LAND USE APPLICATION# o <br /> 0 <br /> m <br /> OWNER NAME Larnmersvllle Unified School District PHONE (209)836-7400 y <br /> OWNER ADDRESS 111 De Anza Blvd. CITY/STATE/ZIP Tracy, CA 95391 <br /> CONTRACTOR Middle Earth Geo Testing, Inc. PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 N Lemon Street CITY/STATE/ZIP Orange, CA 92767 <br /> SUBCONTRACTOR/CONSULTANT BSK Associates PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr. #160 CITY/STATE/ZIP Rancho Cordova, CA 95670 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 899451 ExPIRATION DATE 06/30/2021 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> It dinerenl from Owner: Water System Name Contact Name or Phone Num her <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) a of borings X Geotechnical�_a of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 50 ft Excavation 1.5 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter ; Conductor Casing Depth h <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 ft X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack m1x/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall X Other CPT rods/tremmie Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions'.Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKER MPENSATION LAWS. <br /> 1 I. U 48 UR AD VA CE NOTICE REQUIRED F NSPE IO S -P VVI./S,EAC L 209)953-7169' ,1 <br /> SIGN TITLE A DATE (Z'2 �z V <br /> Y <br /> III if T- <br /> F ANT <br /> �O <br /> - 4 ?0?D <br /> CO <br /> C p14 F,V U/V <br /> RTi„FNT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date hA 3J aOr'D Area S <f Gj Employee ID# L — <br /> Grout Inspection By F1 Dale li SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By p ate Constructed Well D ft <br /> COMMENTS hifl ll—ISI tL✓ �( O✓k� �y N IlUpth� i <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted ervice Re uest# <br /> l <br /> E1,0:3-Gb 601,2019 /X,523 <br /> ,52 3� WELL/PUMP PERMIT <br />