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793 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNT`(ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTICi�a EXPIRES 1 YEAR FROM DATE ISSUED <br /> 11104 W Trac Blvd m <br /> Jos ADOress y CITY/ZIP Tracy,CA 95304 m <br /> D <br /> 0 <br /> CROSS STREET N Tracy Blvd AP,1 212-13-019 PARCEL SIZE 37.96 LAND USE APPLICATION <br /> im <br /> tA <br /> OWNER NAL1E Marca Bella Farms PHONE ± <br /> i <br /> OWNER ADDRESS 10876S Tracy Blvd CITY/STATE/ZIP Tracy,CA 95304 <br /> CONTRACTOR Delta dump Inc- PHONE ( 209 ) 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE a C-57 CXC-61 D-09 Other NUMBER 1055434 _ EXPIRATION DATE 8/16/20 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring :: Soil Sampling/Characterizationp; <br /> L Public Water System <br /> If different from Ovmer. WatorSystem Name Lon,aclami e or Phone Nurr."r <br /> �c � <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well Well Alteration/Modification ❑ Other Q <br /> „ m of borings 30 <br /> C Monitoring Well(s) r of wells Soil Boring(s) Geo technical <br /> ❑ Out-Of-Service Well = Out-Of-Service Well Renewal =: Cross-Connection Repair ✓94 470 <br /> 'New Pump Pump Replacement ❑ Pump Repair Raise Well Casing /y -V/ QU/ <br /> WELL CONSTRUCTION <br /> h <br /> lop <br /> FNT C <br /> Drilling Method Mud Rotary Air Rotary C Auger E Cable Tool _: Push Point Other gRTMc <br /> Proposed Well Depth ft Excavation in diameter Open Bottom . Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched G Steel ❑ Plastic ❑ Stainless Steel Other <br /> Grout Seal Depth 11 Neat Cement(94 ib ba915-10 gal water) Sand Cement sack rnix17 gal water <br /> it Bentonite(20%solids) Other <br /> Grout Placement Method 17 Pumped .. Frcc Fall E. Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor ❑ Other <br /> C Concrete Pedestal Dimensions:Width it Length it Thick in Christy Box Stove Pipe <br /> IPUMP XSubmcrsible❑ Turbine .. Other HP 3.25 Pump Set ft Standing Water Level it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNT`! 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 COM -N —ON LAWS. <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGiJLD f/ TITLE CEO DATE _ <br /> I <br /> xt • 4 y : <br /> D E P A R T M E N ` US E ONLY <br /> Application Accepted By � C Date r �J a)Jo�� Area CC�r Employee ID# r C <br /> k <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By t'L+�[�5�� � .rr,e L a j Date 11t2o f Do W WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check# Amount Permit/ <br /> Info B as Date Remitted Service Re uest# Invoice# Well ID# <br /> X1381 os-D /601�76/ 7 70" <br /> i <br /> EHO 43.00 <br /> WELL/PUMP PERMIT <br /> 8!04108 <br />