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21 1 9 9 iU <br /> WELL/PUMP PERMIT 'I;,��(j�LEYE h <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 /> i <br /> Joe ADDRESS 768 W Fedora Rd CITY/ZIP�erjCh Camp, 95231 m <br /> S Lockhart Rd. D <br /> CROSS STREET APN 1 93-25-024 PARCEL SIZED . 3 6 LAND USE APPLICATION# C <br /> OWNER NAME Clarence Ss'lva <br /> PHONE 408-858-4325 <br /> OWNER ADDRESS 2220 Uridias Ranch Rd. CITY/STATE/ZIP Milpitas, CA 95321 <br /> CONTRACTOR Delta Pump .q pn('KT0 N ARMATURE & MOTOR WORKS M16a. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP_ Stockton CA 95203 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE)ZIP <br /> LICENSE . ❑ C-57 X C-61 0 D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1� <br /> GEOGRAPHICAL INFORMATION: COofdinates X Y Township Range Section <br /> INTENDED USE EXDomestic/Private O Irrigation/Agricultural 0 Industrial O Water Quality Monitoring O Soil Sampling/Characterization <br /> 0 Public Water System <br /> V11 <br /> If differ from Owner: a er ystem ame on ac Name or one um er <br /> TYPE OF WORK O New Well O Replacement Well 0 Well Alteration/Modification O Other <br /> C Monitoring Weil(s) #of wells ❑ Soil Boring(s) #of borings ��n�9s <br /> ❑ Geofechnicat <br /> ❑ Out-Of-Service Well O Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pum Pum Replacement ❑ Pum Repair ❑ Raise Well CasingSqN 9 ?019 <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary O Air Rotary ❑ Auger O Cable Tool ❑ Push Point ❑ Other H��b�NM�NrA <br /> (Proposed Well Depth - <br /> ft Excavation in diameter ❑ Open Bottom O Gravel Pack/Gravel Size <br /> in diamftr <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/GaugelASTM Sched ❑ Steel O Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement <br /> C Bentonite(20%solids) O Other sack mrxf7 gal water <br /> Grout Placement Method O Pumped O Free Fall O Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ ubmersibleD Turbine ❑ Other 1 HP Set <br /> — Pump ft Standing Water Level ft <br /> I 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED <br /> TITLE CEO DATEir <br /> • • Approximately 160 <br /> ft.from Fedora <br /> • <br /> 77 <br /> TTl <br /> D PARTMENT USE ONLY <br /> Application Accepted 8y Dat t! Area_�� <br /> Employee IDt� �� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By A4�Q;��:� \\��b�� �1Date )'� 1 ` �� WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS ft <br /> PE SC Received Chec Amount <br /> Codes Info g Date Permit/ <br /> Cash Remitted Service Re nest# Invoice# Welt ID# <br /> 32,34 'J <br /> EHO 43-06 <br /> 8/04/08 <br /> WELL/PUMP PERMIT <br />