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19487 WELL/PUMP PERMIT /Z <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 1(x$9 q- T.AMMFRq $[p CITY/ZIP TRACY 95304 <br />CROSS STREET_ WEST -MIDDLE RD APN2O9-29-015 PARCEL SIZE 4Q-UANDUSEAPPLICATtON# <br />OWNER NAME """ T' --" —_ ��/AdIIS�» •/,�• i •� <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS 646 S. California Street <br />SUBCONTRACTOR <br />SUBCONTRACTOR AODR£SS <br />LICENSE 0 C-57 X C-61 0 D-09 0 Other <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PHONE209 649-7627 <br />CITY/STATEIZIP � � gS3o� <br />bl3Q.-209-466-9625 <br />CITYISTATE/ZIP Stockton, CA 95203 <br />PHONE <br />CITYISTATE/ZIP <br />NUMBER 724778 EXPIRATIONDATE_ 08/11 <br />Township Range Section <br />vvineaucarnvate a irrigation/Agricultural C Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Ovmer: a er ys em ame C-11taut Name or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification <br />G Monitoring Wells) . # of wells i; Soil Boring(s) <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal <br />❑ New Pumn r? Pumn P -1--i XP%M .-- <br />❑ Other mrrq I- <br /># of borings # of <br />Ci Geotechnical I <br />0 Cross -Connection Repair MAY 2 c Z017 <br />__-0 Raise Well Casing - U <br />.1—fN Cc <br />Drilling Method C Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other Ham")oEWRof FNM T <br />Proposed Well Depth It Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic C Stainless Steel 0 Other <br />Grout Seal Depth ft C Neat Cement (94 !b ba9/5-10 gal water) C Sand Cement <br />sack mlx17 gal water <br />Bentonite (20% solids) :] Other l <br />Grout Placement Method 0 Pumped 0 Free Fall 0 OtherI <br />0 Retardant /Accelerator (name) <br />PFnFRTAI 1 #..1! <br />^mow �r � �f v rump contractor <br />C Concrete Pedestal Dimensions: Width — <br />0 Other <br />ft Length ft Thick in 0 Christy Box 0 Stove Pine <br />IEVmr X)pUbmersible0 Turbine 0 Other <br />HP 1� Pump Set 4n ft Standing Water Leve! IL -E 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO DAT,5/ 2 2/ 2 0 17 <br />NOTE: THIS WAS AN EMERGENCY ISSUE OF NO WATER <br />TO THE HOME. WE HAD TO PULL THE PUMP PRIOR TO YOU <br />RECEIVING THIS APPLICATION. <br />AND WATER I nrr� 1 �tT11 ru[ Ino is nnnir <br />Louise Fornos <br />Office Manager <br />u r V A K I M E N T U S E O N L Y <br />Applit ation Accepted By_ <br />Soil <br />COMME <br />v, <br />mm <br />A <br />v <br />O <br />to <br />!n <br />811? <br />Dattoe <br />Grout Inspection By —T _ Area �__ Employee ID# <br />Pump Inspection By <br />SPECIAL Well Permit <br />a �t7 WAIVER Received <br />3oriLnIg eetion By Date <br />��SS til Constructed Well Depth <br />ft <br />PE SC Received C ' <br />Codes Info Q Amount Date Permit/ <br />I as Remitted Service Re uest # Invoice # Well ID# <br />��- I W POD3�Y�3� <br />EHD 43.06 <br />8/04/O8 <br />WELL /PUMP PERMIT <br />