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ehwellandseptiepermits@sjgov.org <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IVVIV-KEI-UNUABLE rLHMII www.stgov.orgiena <br />CAYIKGJ I TtAK FKUM UAIt ISSUtU <br />Jos ADDRESS 1551 Dove Drive <br />CITY/ZIP Tracy 95376 <br />CROSS STREET MIts Wau APN 24204049 <br />PARCEL SIZE 4.7 ac LAND USE APPLICATION # <br />OWNER NAME The City of Tracy, attn Ilene Macintire <br />PHONE 209-831-6454 <br />OWNER ADDRESS 333 Civic Center Plaza <br />CITYISTATE/ZIP Tracy, California 95376 <br />CONTRACTOR Rockridge Geotechnical, Inc. attn Katie Dickinson <br />PHONE 5105044183 <br />CONTRACTOR ADDRESS 270 Grand Avenue <br />CITYISTATE/ZIP Oakland, California 94610 <br />SUBCONTRACTOR/CONSULTANT Benevent Building <br />PHONE 925-595-5338 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 5377 Meadow Wood Place <br />CITY/STATE/ZIP Concord, California 94521 <br />LICENSE VC -57 C-61 D-09 Other <br />NUMBER 798269 EXPIRATION DATE 6/30/2022 <br />BILLING PARTY: _ OWNER CONTRACTOR <br />fl SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring VSol 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 %/Geotechnical 5 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />(Drilling Method Mud Rotary Air Rotary */Auger i i Cable Tool Push Point Other <br />Proposed Well Depth 15 It Excavation 6 in diameter Fi Open Bottom Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter / Conductor Casing Depth ft <br />N/A Well Casing Diameter _ in Thickness/Gauge/ASTM Sched —F i Steel i Plastic i Stainless Steel i Other <br />Grout Seal Depth 15 ft ✓Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped VFree Fall VOther tremie if applicable Retardant / Accelerator name <br />PEDESTAL N/A Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length ft Thick in Christ Box _ Stove Pipe <br />PUMP N/A _ Submersible. Turbine Other HP Pump Set ft Standing Water Level It <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 />WORKERS COMPENSATION LAWS. <br />MIN114�,�jpd.y�HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED '7�)! TITLE UAAlnAr DATE 9/3/2021 <br />Q <br />m <br />F YMFNT <br />C�cjV�,D <br />h. <br />.Y <br />i!0NMFCOU <br />NT <br />DE'°gRTM�NTY <br />D4,,PAFYTMENT U E ONLY Q-('�1�/ <br />Application Accepted By ate 7/ Area ��2! �!-" / Employee <br />Grout Inspection By . ' - Date ,SPECIAL ell Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#I Amount Date <br />Codes Info Ps op _ dash remit:ed <br />Service Request # Invoice # <br />Well ID# <br />EHD 43-O6 6/1112019 WELL /PUMP PERMIT <br />