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18000 T-3 WELL/DUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.1697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 1777 W_ T,TNNF Rn CITY/zipTRACY 95304 m <br /> n <br /> CROSS STREET T S iynR Tit Rc)kj D APN 2 3 9-2 2-01 0 PARCEL SIZE 4 5 2 _ QND USE APPLICATION# m <br /> N <br /> OWNER NAME HAT, RORRRTSON PHONE 209 914 1392 <br /> OWNER ADDRESS 27337 S. BANTA RD. CITY/STATE/ZIP TRACY CA 95304 <br /> CONTRACTOR Delta Pump_STnc xTnN ARMATi RF & MOTOR WORKS 0"1-NGh. 209-466-962.5 <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 _ 0 Other NUMBER 724778 EXPIRATION DATE 08/1�' <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 0 Domestic/Private ti Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name ContaCt NaFnU or Phone Num5er <br /> TYPE OF WORK 0 New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings 0 Geotechnical of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum Pump Replacement ❑ Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation In diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size in diameter) <br /> 0 Conductor Casing In diameter / Conductor Casing Depth ft l <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) J <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick In ❑ Christy Box 0 Stove Pipe <br /> PUMP 0 SubmersibleO bine 0 Other HP 2 0 0 Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT .I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE f I <br /> PUMP/WELL is located <br /> On the north side of W. <br /> Linne Rd. <br /> qVIRrAill <br /> PEN 11CkTH <br /> DEPARTMENT U(SE ONLY <br /> Application Accepted By Date 7�1 I, Area Employee ID#�(� <br /> (� <br /> Grout Inspection By Date IPE�IAL W011 Permit <br /> Pump Inspection By / Date O `\ WAIVER Received <br /> Soil Boring'[nspecti on By Date Constructed Well Depth <br /> COMMENTS <br /> PESC Received NG eck#/ AmountPermit/ <br /> \ <br /> WN(P <br /> Codes Info B Date Invoice# <br /> Cash Remitted Service <br /> Re uest <br /> EHD 43.08 <br /> 8/04/08 WELL/PUMP PERMIT <br />