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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />GV <br />JOB ADDRESS 0 (37.686044, -121.480037) CITY/ZIP Tracy, 95377 <br />t 25106016 <br />CROSS STREET. rlesi I Ft -0 1��/- APN PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME Tracy Phase 2, LLC PHONE (949) 720-3612 <br />OWNER ADDRESS 888 San Clemente Drive, Suite 100 CITY/STATE/ZIP Newport Beach, CA 92660 <br />CONTRACTOR ENGEO Incorporated PHONE 209-684-7615 <br />CONTRACTOR ADDRESS 17278 Golden Valley Parkway CITY/STATE/ZIP Lathrop, CA 95330 <br />SUBCONTRACTOR <br />West Coast Exploration PHONE (209) 985-7541 <br />SUBCONTRACTOR ADDRESS P O BOX 133 CITY/STATE/ZIP Escalon, CA 95320 <br />LICENSE C-57 C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 01-31-2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/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 <br />Monitoring Well(s) # of wells <br />Out -Of -Service Well <br />Well Alteration/Modification Other <br />Soil Boring(s) # of borings X Geotechnical <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />2 # of borings <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 20 ft Excavation 4 inches in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 90 ft X Neat Cement (941b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped 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 />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 />MINIMU*48 HOUR ADV4NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Z Date 10 1 % <br />Grout Inspection By Date <br />Pump Inspection By Date /� �J <br />Soil Boring Inspection By Date' er"_/ � <br />COMMENTS <br />Area S Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />N <br />m <br />m <br />0 <br />0 <br />0 <br />m <br />m <br />PE SC Received Check#/ <br />Info B Cash <br />Amount Date PePermit]Codes <br />Remitte Service Request # Invoice # Well ID# <br />y37.) <br />P00 (9 7 <br />EHD 43-06 revised 4/14/18/�S �-72_ /S7 WELL /PUMP PERMIT <br />