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I � / V ' <' 18G+30 T-5 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232 - (209)468.3420 NON-I REFUNDABLE PERMIT CALL(209)953.7607 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1 rn JOB ADDRESS 1 777 W- T,TNNF Rn CITY/ZIP TRACY 95304 > (.!ROSS STREET T 5 NORTH R9UNL) APN 2 3 9-2 2-010 PARCEL SIZE 4��.4ND USE APPLICATION# o OWNER NAME HAT, ROBERTSON PHONE 209 . 914 1 392 OWNER ADDRESS 27337 S. BANTA RD. CITY/STATE/ZIP TRACY CA 95304 CONTRACTOR Delta Pump-gTnnxTnN ARMA'TiTRF & MOTOR WORKS Mh. 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 X C-61 ❑ D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/16 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE 0 Domestic/Private 0 irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampiing/Characterization 0 Public Water System If different from Owner: Water 6ystem Name ------0—onFa-crR5me or Phone Numl3er TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modificatlon 0 Other ❑ Monitoring Wells) #of wells 0 Sol[Boring(s) #of borings 0 Geotechnical #of borings ❑ Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair ❑ New Pum Pump Replacement 0 Pump Repair 0 Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other Proposed Well Depth ft Excavation In diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter 0 Conductor Casing In diameter / Conductor Casing Depth ft Well Casing Diameter_ In Thlckness/Gauge/ASTM Schad 0 Steel ❑ Plastic 0 Stainless Steel ❑ Other Grout Seal Depth ft 0 Neat Cement(94 Ib bag/5.10 gal wafer) 0 Sand Cement sack m1x/7 gal wafer 0 Bentonite(20%solids) 0 Other Grout Placement Method 0 Pumped ❑ Free Fall 0 Other 0 Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe I i PUMP ❑ Submersible❑)';<tXbine ❑ Other HP_2 0 0 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. I 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. IMUIVI 2 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION ` SIGNED TITLE CEO ' DATE I PUMP/WELL is located approx.0.6 miles from W.Linne Rd.North a VI EAA " DEPARTMENT USE -O/N'ONLY /� Application Accepted B _ �� Date _ �!_/G� Area_` Employee ID#I- �__ Groyt Inspection By ' _ Date_ " (( SPECIA Well Permit Pump Inspection By Date WAIVER Received Soil Boring ins action By M.+. Constructed Well Depth ft COMMENTS V i k pp D�vE. R E 11��11�E;VED PE SC Received heck Amount Permit/ Codes info B Date Cash Remitted ServiceRel uest# InIV 1 8 2015 Well ID# 66 N JOAOUI COUNTY oyfl FNVIH Ir R7MENT I EHO 43.06 8/04/06 WELL/PUMP PERMIT