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21198 (t+� <br /> WELL/PUMP PERMIT n�T t� <br /> Ltd <br /> SAN.iOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209) 6 - <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> i <br /> JOB ADDRESS 26600 Hansen Rd. CIn,/zIP Tracy, 95377 m <br /> CROSSSTREET Robert T. Monagan A�Vy209-23-01 9 n� C7 <br /> PARCEL SIZE 1 .7 �L`AND USE APPLICATION m <br /> OWNER NAME Angel Peres 951 -360-9516 Cn <br /> PHONE <br /> OWNER ADDRESS PO Box 111 CITY/STATE/ZIPJurupa Valley, CA 91 75 <br /> CONTRACTOR Delta Pump cTC�C'KTf�N ARMATIJRF & MOTOR WORKS ffMh. 209-466— 625 _ <br /> CONTRACTOR ADDRESS 646 S. California Street CITYISTATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE C C-57 X C-61 D-09 D Other NUMBER 724778 EXPIRATION DATE 08/' l <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private D Irrigation/Agricultural C Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Character zation <br /> Public Water System <br /> If different from Owner: Water ys em Name on ac ame or one Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well C Well Alteration/Modification U Other <br /> G Monitoring Well(s) #of welts Soil Boring(s) �ofborrtgs T <br /> D Geotechnical ` <br /> Out-Of-Service Well D Out-Of-Service Well Renewal C Cross-Connection Repair <br /> New Pump aKump Replacement C Pump Repair <br /> -7 Raise Well CasingEdi <br /> WELL CONSTRUCTIONn <br /> Drilling Method C Mud Rotary Air Rotary ❑ Auger ❑ Cable Tool C Push Point D Other SAN 0�9 <br /> Proposed Well Depth ft Excavation in diameter C Open Bottom ❑ Gravel Pack/Gravel Siz <br /> N �r�C <br /> Conductor Casing in diameter / Conductor Casing Depth <br /> _ ft <br /> ART <br /> Well Casing Diameter in Thickness/GaugeiASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel D Other MENT <br /> ` Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) C. Sand Cement <br /> sack mix17 gal water <br /> -. Bentonite(20%solids) ,:, Other <br /> ,Grout Placement Method D Pumped C Free Fall :� Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller C Pump Contractor C Other <br /> C Concrete Pedestal Dimensions Width ft Length ft Thick n ^ Christy Box L) Stove Pipe <br /> au_MP XSubmersible^ Turbine C Other <br /> HP Pump Set 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 /> I <br /> "'NIIN M 24 H>>UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS j <br /> SIGNED <br /> I ITLt _";EG MA-E 4/26/19 <br /> Approximately 183 a -.'T <br /> ft.from Hansen Rd <br /> ip <br /> I t r r <br /> I •- i IJ , <br /> PA/�2 I MEN , U E jJNLY <br /> Application Accepted By <br /> Area Employee ID#b <br /> Grout Inspection By l - Date PECIAL Well Permit <br /> Pump Inspection By J �, F <br /> 1 �r _ Date�f� � WAIVER Received <br /> Soil Boring Inspection By <br /> COMMENTS Date Constructed Well Depth ft <br /> PE SC Received hec <br /> Amount Permit/Info 8 ash Date <br /> Remitted Service Re uest# Invoice# Well ID# <br /> EHO 43-06 <br /> 8!04/08 <br /> WELL/PUMP PERMIT <br />