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17788 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 768 _ W. FEDORA ST. CITY/ZIP FRENCH CAMP 95231 m-I <br /> D <br /> CROSS STREET S 1:LOCKHART APN 1 9 3-2 5-0 2 4 PARCEL SIZE 0- 3 6 LAND USE APPLICATION# <br /> OWNER NAME CLARENCE SILVA PHONE408-858-4325 m <br /> OWNER ADDRESS 2220 URIL)IAR CITY/STATE/ZIP MILPITA CA 95035 <br /> CONTRACTOR Delta Pump -STOCKTON ARMATURE & MOTOR WORKS PHONE' 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 0 C-57 X C-61 0 D-09 ❑ Other NUMBER 724778 IRATIONDATE 08/16 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y T Wnship Range Section <br /> INTENDED USE RRomestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monit I ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water ys em Name on ac ame or one um er <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification d6ther <br /> 0 Monitoring Wells) #of wells 0 Soil Boring(s) Vorings ❑ Geotechnical of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewa0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement XVump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 C le Tool /❑ P oint 0 Other <br /> Proposed Well Depth it Excavation in diameter pen Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / C ductor Cas th ft <br /> Well Casing Diameter_ in Thickness/Gauge/A TM Sche 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cem nt(9, <br /> 9 g1 <br /> 5-10 a ter) 0 Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall ❑ th 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0Pump C aC r/ 0ther <br /> 0 Concrete Pedestal Dimensions:W h length ftThick in 0 Christy Box 0 Stove Pipe <br /> PUMP D[Rubmersible0 Turbine 0 Othe H> 1 Pump Set 82 ft Standing Water Level ft <br /> PA D <br /> I HEREBY CERTIFY THAT I HAVE PREIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE L . S, Mb RUL ES AND REGULATIONS. I ALSO CERTIFY THAI' MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFOR I CONTRACTORS STATE LICENSE BOARD AND THAT.I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> INIMU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 9/17/2015 <br /> t7lg <br /> Pump/Well is located behind the FRONT SINGLE FAMILY <br /> front house alpng the back fence DWELLING 768 W.FEDORA <br /> that separat�s the front and back <br /> houses.Approx.8 ft.from the East <br /> fence. <br /> -_ <br /> "W IG1vr w <br /> SINGLE AMILY DWELLING = <br /> 777 U/ FFnr1RA <br /> "" wllaG, t LTH <br /> s <br /> /I DEPARTMENT USE ONLY <br /> Application Accepted By/ �j� Ne�r.!� Date'L�-� ( Area Employee ID#,10__ �- <br /> Grout Inspection By N Date SPECIAL Well Permit <br /> Pump Inspection By , Date C t _1 WAIVER Received <br /> Soil Boring Inspect'on By Date Constructed Well Depth ft <br /> COMMENTS tUl U <i it- �- bo btu .an wz <br /> +- l <br /> PE Sc Receivedeck#/ Amount Permit/ <br /> Codes Info B hash Remitted Date Service Re uest# Invoice# <br /> O)v .� t D(,o SQOo 7.319Z- SANS 2201j; <br /> • yF �iq �N <br /> NTA <br /> 1. <br /> EHD 43.06 WEL ERMIT <br /> 8/04/08 <br />