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L <br /> 20051 <br /> WELL/PUMP PERMIT <br /> PAN 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 /> U1 <br /> JOB ADDRESS 2-8877 S_ cHRTSMAN Rn_ CITY2IP TRACY CA 95304 n <br /> v <br /> CROSS STREET wT•T NN T E Rl) APN 253-22-005 <br /> PARCEL SI2E1 5.3 5 LAND USE APPLICATION# <br /> m <br /> y <br /> OWNER NAME MARIE BARE TTA PHONE 484-6658 <br /> OWNER ADDRESS SAA4E CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump__qTnCKT0 N ARMATugE & MOTOR WORKS mmit.209-466-9625 <br /> CONTRACTORADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 X C-61 0 D-09 0 Other NUMBER 724778 EXPIRATIONDATE 08/M <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 0X¢mestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 0-Soil Sampling/Characterization <br /> C Public Water System <br /> If different from Owner Water bystem Name Gontact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other yes <br /> ❑ Monitoring Well(s) #ofweffs ❑ Soft Boring(s) #of borings ;y <br /> ❑ Geotechnical <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair FEB 9 <br /> ew Pum 0 Pum Replacement 0 Pum Repair 0 Raise Well CasingCCD f Z 201 <br /> WELL CONSTRUCTION <br /> SAENVIRRONU COON <br /> Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size DEPIM.E W <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_, in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic 0 Stainless Steel ❑ Other <br /> Grout Seat Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixR gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> C Concrete Pedesta)Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> 1 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 W CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSAT16N LAWS. <br /> MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO <br /> DATE�1612018 <br /> I <br /> � eM <br /> PUMP/WELL is located approx. <br /> r 30 ft from the back of the <br /> garage. <br /> IF <br /> 4 # 1. <br /> 1 - <br /> DE ARTMENT U E 7NAY <br /> Application Accepted By Date 2 Area/% 1 Employee ID <br /> Grout Inspection By Date `SPPEItE CIAL-Well Permit <br /> Pump Inspecti6D.•By Date WAIVER Received <br /> Soil Boring Inspecti$$n B�. Date Constructed Well Depth ft <br /> COMMENTS '. <br /> PE SC Receivedc Amount Permit/ <br /> Codes Info 5. B Remitted Date Service Re uest# Invoice# Well 1D# <br /> �dss a 21�� UP00 C' <br /> f <br /> EHD 4306 <br /> 8/04/08 WELL/PUMP PERMIT <br />