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- 796 0 WELL 1 PUMP PERMIT <br /> SAN]OAQUIN .111 Y ENVIAONM MAL Ta DEPAitTmLKT 600 E.Main Street .CA 95202 -{209)46&3420 <br /> NON-REFUNDABLE PERMIT CALL 09 953-7697 Fora JNSPECTIoNs It,, -en S I YEAR FROM DATE ISSUED <br /> JOB ADDBF_SS 19775 Tom Paine Cny/zgp Tracy 95304 <br /> "OSS Srt rr Delta APN ,213-020-30 pARcst.Srse-;-2-i!�LAem us.A.:A. <br /> OWNrRNAmE Ernie CostamagnaPRONE 559-26 32 <br /> ! OWNER ADDRESS same CrTv1STATEZiP - <br /> 1!+ CONTRACTOR Delta PumR _ noNE-20--466-9625 <br /> CoNmAcmRADDneu 646 S. California Street Crrv/SrArel/rr >Ckton, CA 45203 <br /> SuecoNmeron <br /> PHONE <br /> I` SUBCDNTRACMR ADDRESS CTIYISTATEMP <br /> ` r Wcsns6 13 C-57 )CXC-61 0D-09 13 Other Ntnmrs 72477$ FapatATsaNDAT¢ $ 0$ - <br /> GKOGRAPRICAL INrnwaAmoN: Coordinates X Y Tarnship Range SscdoR <br /> D UsB �Domest]UPtivpte ❑Irri ation/A rncultural I3 Industrial Q Water <br /> ..i 1 .1:�_ .- E. g _ F . . quniity Monitoring p Sail StunpliDglC:hancteriulion <br /> O Public Watersystem <br /> 'If diHneai eeai Dwner: i esrr )*cr5 =cCoat=N—a ftm.limber - II,�, <br /> TYPE OF WORK ❑New Well O Replacement Well 0 Well Altendon/Modificadon C Other 1A '1 <br /> .. aeftwringa Mofhor]gtr <br /> O Monitoring Welt(a) #ofwclls 0 Sot?Baring(s) ❑Gcotxhniwl <br /> ❑Out-0PServ]ce Well ODN <br /> OOf-Service Well Renewal 13Cruss.CDnnection Repair <br /> M'3N W N 0 Pum Re leeement 11 v <br /> W ELL COMMUL-FTON <br /> Drildng Method 0 Mud Rotary 0 AifRotary 0 Auger 0 Cable Too] 0 Push Fobs OOther. <br /> I Proposed Well Depth fl .Excavation in diameter 0 Open Bottom O Gravel Pack/Gravel Sim in diameter <br /> I s O Conductor Cesing ]n diameter I ConduclorCasing Depth-- R <br /> Well Casing Diameter_-._y._to ThicknesslGaugdAST i Sched ❑Steel ❑,Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth R 0 Neat Cement(941b bogl S-10ga!)velar) []sand Cement sack aria 17 gal water a <br /> 0 Bentonite(2096 solids) 0 Manufacturer Spec%solids _ % Name 0 Specs on File 0 Specs Submitted <br /> t}� <br /> ` Grout Placement Method 0 Pumped ❑Fru Fall - 0 Otho 0 Retardant/Acceletator(name) <br /> ep oErrAr` Installed By ❑Driller ❑Pump Coaa=or 0 Other <br /> O Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Boa l3 Stove Pipe <br /> )`SSS£ ®Subtnersthb.CI Turbine 0 Other HP 1 P=PS—t. 10 ft Bland Water Level 8 <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAW& <br /> 1NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> l:,j SiGNED nnz CEO <br /> S:I <br /> k <br /> l <br /> r <br /> ;! 4 <br /> DEP RTMENT• USE 0 N L V �,��/�f <br /> Application AeceptW B Date AreaPmpinyeet[1!1LL[!Y'�T— J <br /> Grout inspection By Date ❑ SPECIAL Well Permit <br /> Pump laspcwon By Date- ❑ WAIVER Received <br /> Cowtrucled Werptb <br /> COMMENTS <br /> i <br /> PE Se Received Cheelaw Amount Permit/ <br /> By CashRcmittsd Date Service Rr pert# Invoice p Well EM <br /> 0 -27&33 <br /> M <br /> a <br /> t <br />