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'10330 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 ISStIFn <br />JOB ADDRESS 9262 LORRAINE RD. CITYIZIP TRACY 95377 <br />CROSS STREET MACARTH UR ApN 248-06-025 PARCEL SIZE 0. 9 7 <br />LAND USE APPLICATION # <br />OWNER NAME GLORIA DAVIES r PHONE 209 380 7660 <br />OWNER ADDRESS SAME CITY/STATE/Zlp <br />CONTRACTOR Delta Pump STnr•xmnN AgMATr1RF & MnTn'R WD KS tea, 209-466-96 <br />25 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP _Stockton. CA 95203 <br />SUBCONTRACTOR ADDRESS <br />LICENSE 0 C-57 X C-61 0 D-09 0 Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 724778 EXPIRATION DATE 08/ <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />uxt finesacn-nvate a irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampl—ing/CharagLerization <br />C Public Water SystemA '"M. <br />If different from Owner. Water ys em Name tact Name or Phone Numb _ <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />G Monitoring Weli(s) # of wefts O Sort Boring(s) # of borings ❑Geotechnical 9{borings <br />❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair �/ 72018 <br />0 New Pump &RR mp Replacement 0 Pump Repair 0 Raise Well Casino 4�vit), ... <br />- H •,rcpNMEN "ryTY <br />Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point 0 Other DEPART �. <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seat Depth ft 0 Neat Cement (94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fail 0 Other n PW—A—t r A-1--, r <br />PEDESTAL installed By ❑ Driller ❑ Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy BOX ❑ Stove Pipe <br />PUMPOX6bmersible ❑ Turbine 0 Other HP 0 . 7 5 HPPump Set ft Standing Water Levelft <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. !ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAZlS_ <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />2Z.C�gfiI-- TITLE CEO <br />Date <br />Date S _ <br />Date 3 <br />Soil Boring Inspection By Date Constructed Weil Depth <br />COMMENTS <br />DATE 5010 /2Q`1 8 <br />Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Codes l Info <br />Date <br />,.c,rr,ttGa Service Request # <br />Invoice # I Well ID# <br />EHD 43-06 <br />8/04108 WELL /PUMP PERMIT <br />m <br />D <br />0 <br />m <br />