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t r <br /> 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 /> LA <br /> JOB ADDRESS 16555 Von Sosten Road (Lammersville ES) cITymp Tracy, CA 95304 <br /> CROSSSTREET Hansen Road APN 20914009 PARCEL SIZEA3L—LAND USE APPLICATION# <br /> OWNERNAME Lammers 'Ile Unified School District PHONE_(209)836-7400 <br /> OWNER ADDRESS 111 De Anza Blvd. CITY/sTATEZP Tracy,CA 95391 <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street crrysTATmp Escondido, CA 92029 <br /> SUSCONTRACTOR/CONSULTANT RSK Associates PHONE 916-853-9293 <br /> SUBCOWRACTOR/CONSuLTAm ADDRESS3140 Gold Camp Dr.#160 CITY/STATE/ZIP Rancho Cordova, CA 95670 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 804318 EXPIRATION DATE 02/28/2022 <br /> BILLING PARTY: OWNER CONTRACTOR x SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domesfic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings X Geotechnical 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 15 ft Excavation 6-8 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 1511 x Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped x Free Fall Other 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 /> 1 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM <br /> ,(4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED A`/4..)��'���� TITLE-Owner DATE 12/29/2020 <br /> RFq yMF <br /> cAi�iv10 <br /> F T <br /> JoF�j? O <br /> V�R�u 10 <br /> Ty�Fp�� <br /> NT <br /> DEPARTMENT USE NLY <br /> Applicafion Accepted By Date pi Area S Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspectio ByDae onstru d Well DeI It <br /> CO MET v I F cl O"7rCC q-K' O !rh .t <br /> b <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> 37R sh -MI570 <br /> EHD 43-O6 6/11/2019 � )/��� �� WELL(PUMP PERMIT <br />