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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNrV ENVIRONMEsTAL HEALTR DEPARTMENT #13033 600 E.Malo Street-STOCKTON CA 95202 -(209)46W420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECT IONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Durha—Fr Road ~� CyTYIZEP Tracy <br /> b <br /> '5 USE IzE' �F i <br /> CROSS STREET Hi4hway 33 APN C7 PARCELS LANDUSLAPPLICATIONN C/�C1�- <br /> OWNER NAME -,Lombardi FarmsEx,,,r�, /Q-ri� � / -�-�� PRONE 649-6147 <br /> OWNER ADDRESS 15998 GawTte Road CrrvlSrAre/zrP Stockton, CA 95215 <br /> CONTRACTOR Delta Pump PHONE 209-466-9625 <br /> ' CONTRACTORADDRPSs 646 S. California Street Crrv/STATE/Zm Stockton, CA 95203 <br /> SUBCONTRACTOR <br /> PRONE i <br /> SUBCONTRACTOR ADDRESS Crry/SrATx/Zrp <br /> LICENSE 0C-57 XXC-61 C]D-09 ❑Other NUMBER 724778 EXI'MATIONDATE 08/12 <br /> GEOGRAPBiCALINTO;LmAnoN: Coordl u X Y Townsbip RanYt Section <br /> INTENDED USE ❑Domeslie/Private I gation/Agricultuml D Industrial ❑Water Quality Monitoring O Soil SamplingiCharactodzation <br /> ❑Public Water Syy <br /> Ir ddf.cot from Owner: — - vita- 9?;6m N.me Canino Na-orPb-,N—ber <br /> I <br /> Tj?jq v ❑New Well ❑Replacement Well ❑Well Allcrstien/Modiiication ❑Other <br /> ❑Monitoring Well(s) M of wells . O Soil Boring(s) s orbenaV s of bmnax r <br /> ❑Out-O"trvico Well ❑Out-Of-Service Wcll Rtncwal ss-Connection Repair <br /> ❑ <br /> New Pu OP Re lucement ❑Pu Repair Pull. u install sand se era <br /> WELL CONSnUCTION <br /> Drilling Metbod ❑Mud Rotary ❑Air Rotary ❑Auger Cable Tool ❑Push Point ❑Other r� <br /> Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Grovel Pack/Oravoi Size in diameter \/ <br /> ❑'Conductor Casing indiar etet I Conductor Casing Depth fl <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Slainitsa Steel ❑Other <br /> Grout Seal Depth A ❑Neat Cement(94 ib bag/5-10 gal water) ❑Sand Cement rack mix/7 gal water V 3 <br /> t ❑Bcntonitc(2D%solids) ❑Manufacturer Spcc%solids,% Name ❑Specs on Filc O Spocs Submitted <br /> Grout Pia cement Method ❑Pumped O Frce Pall ❑Other O Retardant/A=ICMtor(name) <br /> PEDESTAL Instilled By CI Driller ❑Pump Contractor CI Other i (� <br /> ❑Concrete Pedestal Dimensions:Widtb ft Length flThick in ❑Chri-ty Bos ❑Stove Pipe <br /> HldD ❑Submersible (Ill Turbine ❑Other HP 12.5 Pump Set 280 R Standing Water Levol 62 fl <br /> i <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE Wl1-H SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WMI THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, 1 <br /> MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS i <br /> StcNen Tt7LE CEO DA-m 04122111 <br /> i <br /> Aff <br /> I <br /> f -C EI / <br /> Ulm ti. <br /> IAN CA,•UI C ,.j <br /> DEP A R T M E.IN T U S,E_Q N..L_Y.­,_. :t�r—•ac,.��, s K — <br /> Applkatfon A pted By 'Pate ' / J Ares Employee IDI s_ <br /> Grout lmpcetioa By Date ❑ SPECIAL Well Permit <br /> Pump Inspection ByDate '65; ❑ WAIVER Revelved <br /> OF <br /> Constructed Well Depth R <br /> COMMENTS f� /I <br /> f <br /> PE SC Reeelved (Cfic-oj# Amount Date Permit! <br /> Invoice rY Well mp <br /> Codes Info B ash Remitted Service Request N <br /> 0--50 c;tv QLO 1oa -71 g <br /> 4 <br />