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19314 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 />JOB ADDRESS 1739 N. DURHAM FERRY RD. CITYIZIP TRACY 95304 <br />CROSS STREET CA 3 3 APN 255-31 —023 PARCEL SIZE 1 - 1 4 -AND USE APPLICATION # <br />OWNER NAME <br />c�D ll JCF64j'1 �i 4�1is�I J PHONE. 415-533-0322 <br />OWNER ADDRESS -3 1 4 Q 2�1-- <br />.� CITY/STATFJZIP 3'-RA�'�'--cAn�yz- <br />CONTRACTOR Delta P=—STQC'KTDN ARMATURE & MOTOR WORKS 110Gh. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C-57 N C-61 0 D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/ 11 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />IN I trvutu ust kkomesticirnvate U Irrigation/Agricultural C Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water ys em Narne on ac ame or one um er <br />TYPE OF WORK 0 XKw Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wefts 0 Soil Boring(s) 9 s # of borings <br />>J Geo[echnica! #olborings <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />lk New Pump ❑ Pump Replacement 0 Pump Repair 0 Raise Well Casin <br />WELL CONSTRUCTION <br />Drilling Method C Mud Rotary ❑ Air Rotary ❑ Auger Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 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 D Plastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 Ib bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water <br />C Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP 0 Submersible❑ Turbine C Other HP Pump Set 341 ft Standing Water Level <br />1 HEREBY CER 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 COMPENSATIS. <br />MINIMU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED v ��v�� TITLE CEODATE 5/1 /2017 <br />_ <br />T <br />1m <br />m <br />0 <br />U <br />m <br />m <br />cnN <br />DEPARTMENT USE ONLY <br />Application Accepted By Date � ✓ZZArea Employee ID# o uw s <br />Grout Inspection By Date <br />SPECIAL Well Permit <br />Pump Inspection By tat f' Date 1, 2$rl•�- WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Chec Amount Permit/ <br />s Remitted Date Service Re uest # Invoice # Well ID# <br />EHD 43.06 <br />8/04108 WELL /PUMP PERMIT <br />