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I <br />19985 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN-KEFUNDABLE VERMIT t:ALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 24383 MOUNTAIN HOUSE PRKWAY CITY2IP TRACY 95377 <br />CROSS STREET HWY 205 APN2 0 9- 0 9- 0 3 6 PARRC/E,LL SIZE 3 8yy 3 ZAND USE APPLICATION # <br />OWNERNAME TRACY GRATING AND PAVING IN 4::!� �"`''I�PHONE321 -5025 <br />OWNER ADDRESS W _ 1 2 TH ST _ /� 7 (�( (7A 6V 1 MP CITY/STATE/ZIP_TRACY CA 95376 <br />CONTRACTOR Delta P9mp—STn(`X22nN ARMATURE, & MOTOR WORKS Mhl&. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 X C-61 <br />CITY/STATE/ZIP Q <br />❑ D-09 ❑ Other NUMBER 724778 EXPIRATIONDATE 08/1% <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ranae Section <br />INTENDED USE gRomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water bystem Name Contact Name or Flhone Number <br />1 YPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump Pump Replacement O.Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation 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 Seat Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ 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 kkubmersibleo Turbine ❑ Other HP Pump Set �MRft 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 />_,_.',.�-MINIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED'' TITLE CEO DATE —22-1 7 <br />m <br />ID <br />0 <br />a <br />In <br />N <br />0 <br />�,/AD", ARTMENT SE NLY <br />Application Accepted By �Date Area 0*1 Employee ID#�4 <br />Grout Inspection By DateSPECIA Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />Sc <br />Info <br />ReceivedAmount <br />By <br />Cash <br />Remitted <br />Date <br />Permit/ <br />Service Reguest # <br />Invoice # <br />Well ID# <br />Zo I-7 <br />W Doi-7yq <br />EHD 4306 <br />8/04108 WELL /PUMP PERMIT <br />