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WELL/PUMP PERMIT <br /> Sur JOAOUIN COUNTY EpmPtowEwTAL HEALTH DerwrivENT lata EAST NAZZLTON AvtNUE•STOCKTO.CA 95205 6232(209)468•1120 <br /> NON-REFUNDABLE PERMIT www.sigov.org/*hd EXPIRES 1 YEAR FROM DATE ISSUED LA <br /> Joe ADDRESS 1550 Cypress Orlye UrTrL► Tracy.CA(45376 AS <br /> cROsa stritm AldRn Glen Drive _APN 934 5001 PARCEL Stra 211•LAND Use AP►UCArION s Q <br /> OvniER NAME Tracy Unified School District P»ow 209-830-3200 BGj <br /> OvsWR AOORess 1875 W Lowell Avenue Cn.IST.TE/LP Tracy,CA 95376 <br /> CONTRACTOR Middle Earth Geo Testing Inc. _ PNoNE 714-633-5025 <br /> coNTRAcyoR Aoudiss 954 N Lemon Street Cm1STATEIZI Orange,CA 92767 <br /> SUBCONTKACTMCONSt!LTANT BSK Associates PNoNe 416-R53-9293 <br /> SUBCOMTRACTORICONSULTANT ADDRESS 3140 Gold Camp Dr.#160 CRYISTAtFjzv Rancho Cordova.CA 95670 <br /> UcENSE :!C-57 C-5 t 0.09 O!"x __ NUwaER AC9451 EAPwAnom DATE 06/30/2021 <br /> &LUNO PARTY: OWNER CONTRACTOR :{ SUBCONrRACTOA/CONaULTAwT <br /> DoMeST1C WELL SAKPLOO: General kltnaralrCdtform Batten(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED Use DomesnaPmate Imga'uon/Agncuttural Industrial X Sod SarrPhr g Charactenzatton <br /> Pubic Water system <br /> R:,n�,erl kr 0-1 wrW 5^.-N— CCMAc1 NArt♦Or P^ N�rrbr <br /> TY►E Or WORK New Well Replacement Well Wel Ate ra!t0nM0d41cao0r Oma <br /> Lton'nru,g Wellsr a c!wets Sal Bornrg(s) X Gooterhr'cv�t ti xrrgs <br /> O.t-O'-Serwce Well Out-a-Serrce Well Reeal Cross-Connection Repan <br /> New Pump Pump Replacemem Pump RR .r Raise Well Czts,ng <br /> WEA rr QO%a• <br /> DrM..g Method Mud Rotary Ar Rotary X Auger Cada Tod Push Pant Other <br /> Proposed Well Depth 50 a Eacavatron 1.5.5 in dwmeWr Open Bottom Gra,el Pw-jv&thel Size ,n ciemelar <br /> Ccnductor Casing it diameter ; Conductor Casing Depth ft <br /> Well Casing Diameter_m ThicknesslSaugaASTM Schad Steel Piasbc StanJess Steel Ot^er <br /> Groal Seal Oeptn 50 R X Neat Cement(94 m bays 10 gal*alert Sand Cement sack—17 gal water <br /> Beritorute(20%sdrds) Other <br /> Grout Placement Method Pumped Free Fall Y.Omer CPT rods/trOMMle Retare—I/Acoelerstur(nar•e) <br /> PeoeaTAL Installed By Drtser Pump C—tractor Other — <br /> f Concseb Pedestal Dimensions Width fl Length It Thic. Christy Boa Stoves Pipe <br /> Submern be T,rbme Other HP Pump Set n Standing Water LevelfI <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED TW113 APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCE STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND WRH CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP TION <br /> F.`.!"+"" ^ ANCF NO CE REQUIRED F INSPECTION P SE CALL(209)953-7697 <br /> SIGNED TIT 1'1t,tiWLl 7�'<. DAT>: �'�-2 C) b <br /> l j I <br /> Y <br /> I � � 3 <br /> - oq 2420 <br /> i <br /> 0 <br /> I I , UI <br /> N <br /> li 21-1tr— I Rp C <br /> I I o <br /> N NMF yell <br /> FF:Fj OFp� Nrq Y <br /> II I <br /> I I I <br /> li I ' I I I <br /> it it I III III I I I ! ' <br /> I III II i <br /> DEPARTMENT USE ONLY <br /> Appl"bdn Accepted By � �L— Date 7/3j�-)'"C7 Area 1-> lC•!I Employee IDs SI <br /> Grout inspection By Date SPECIAL Wall Permit <br /> Pump Inspection By ., Date WAIVER Recelved <br /> Sod Bonng Inspection By ? �"'- Otte - � C.W ct d Wal Depth it <br /> COMMENTS <br /> PE SC Received Amourn Day Verm1U Invoice if WNI well <br /> Codes Info Rwnw" I rviu R t t <br /> _ I <br /> AELL•PI.W PEPMT <br />