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19583 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />p, � <br />JOB ADDRESS 132 OHM RD D -7 CITY/ZIP TRA('Y 95304 m <br />CROSS STREET APN_i5P,l-0 8 — Q i l j�PARCEL. SIZE 7 0 . ZG D A <br />USE APPLICATION # f <br />OWNER NAME DEL TERRA PARM4 �` lz/UMw/,r� %f�1�7��� PHONE209 612 5442 <br />OWNER ADDRESS 33600 S. KOSTER RD. '• CITY/STATEIZIP TRACY 95304 <br />CONTRACTOR Delta Pumv ,qTnCTnN AgMATjgF, & MOTOR tangy 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR _, PHONE <br />SUBcONTRACSOR ADDRESS CITYISTATEIZIP <br />LICENSE ❑ C-57 XC -61 ❑ D-09 ❑Other NUMBER 724778 EXPIRATIONDATE 08/11 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE XAOmestic/Private 0 Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: a er ys em ame Uomaut Name or Phone NUMber <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Al teration/Modification 0 Other <br />G Monitoring Wells) # of wells ❑ Soil Borings) # of borings <br />G Geotechnical <br />❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />0 New Pum2 ❑ Pump Replacement x;XPumn Re air <br /># of borings <br />WELL CONSTRUCTION ❑ Ralse Well C -sin <br />Drilling Method C Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation— <br />in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth it <br />Wet! Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) 0 Sand Cement <br />sack mixl7 gal water <br />Bentonite (20% solids) D Other ` <br />Grout Placement Method ❑ Pumped 0 Free Fall 0 Other <br />0 Retardant / Accelerator (name) <br />o� <br />�y a UnuCf a rump contractor 0 Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />m 0 Christy Box 0 Stove Pipe <br />PUMP ,�kubmersible0 Turbine C Other HP Pump Set 1 d n ft Standing Water Level <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 <br />MINIMU 24 HOUR AVANC <br />DE NOTICE REQUIRED FOR INSPECTIONS <br />?IGNED TITLE CEO <br />DATE7/7/2017 <br />i <br />PUMP/WELL IS LOCATED <br />JUST NORTH OF THE <br />TREES <br />SEEINSERT <br />torl2EPARTMDate U E O L Y <br />Application Accepted Sy DateGrout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />IR <br />Are*SPECIAL <br />Employee ID# <br />Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />WELL /PUMP PERMIT <br />X <br />m <br />N <br />