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y � * 19424 WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn JOB ADDRESS _-21 1 20 FL RAN(`Ha RIS CITY/ZIP TRACY 95304 m , D CROSS STREET S. CANAL BLVD, APNZI '/(/Q`�7') ' PARCEL SIZEr; 9 LAND USE APPLICATION# M OWNER NAME TONY S ILVA Jr 1 T PHONE2 0 9 649 RS00 OWNER ADDRESS SAME CITYISTATEIZIP CONTRACTOR Delta Pump-,qTC) 'KT(�N ARMATtlRF & MOTOR WORKS 9A i6h._209-466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 'N C-61 ❑ D-09 0 Other NUMBER 724778 EXPIRATIONDATE 08/11 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE A)Pomestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization 0 Public Water System If different from Owner: Water System ameon ac Name or Phone Number TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification 0 Other O Monitoring Welf(s) #of wells G Soil Boring(s) #of borings #of borings G Geotechnical 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair XR New Pump 0 Pump Replacement ❑ Pump Repair 0 Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger 0 Cable Tool u Push Point ❑ Other Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter G Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft 0 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mixl7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method D Pumped 0 Free Fail u Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller u Pump Contractor 0 Other Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe PUMP Submersible❑ Turbine 0 Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE CEO DATE 5 14 12017 I 771-7 PUMP/WELL Is located approx. 60 ft from the >. i corner of the house '' H LTH NOTE: � PUMP SET&STANDING WATER LEVEL IS UNKNOWN UNTIL THE JOB IS DONE o tiT ,teDEtARTMENTS7 ONLY APVA-bon Accepted By Date 5 /` ( Area Employee ID# jV'0) Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Amount Codes Info B ash Remitted Date Permit/ Rel-e—# Invoice# Well ID# EHD 43-06 8104/08 WELL/PUMP PERMIT