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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE LION AVENUE•STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> Joe ADDRESS 92492 5 MacArthur Rd CITY/ZIP Tracy CA 95377 y <br /> J� 0 <br /> CROSS STREET W.Linne Rd. APN 253-150-6e D V PARCEL SIZE 6tLLAND USE APPLICATION#� m <br /> OWNER NAME Robert Chartier <br /> PHONE510-396-7579 ' zLt7 1 }- s L <br /> OWNER ADDRESS 32932 S.MacArthur Rd. CITYISTATE/ZIP Tracy,CA 95377 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR Martell Water Systems.Inc. PHONE 925-432-4262 <br /> SUBCONTRACTOR ADDRESS 1818 Loveridge Rd. CITY/STATE/ZIP Pittsburg,CA 94565 <br /> LICENSE ./C-57 /C-61 D-09 Other D-21 NUMBER 510952 EXPIRATION DATE 5/31/17 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE V Domestic/Pnvate - IrrigalioniAgricullural Industrial Water Quality Monitoring - Soil SamplingiCharactenzation <br /> Public Water System <br /> it a,Rerent Ircm Owner. t-'oysl— ,m.. on a amu or P hone umoer <br /> TYPE OF WORK New Well - Replacement Well Well Alteration/Modification - Other <br /> - Monitoring W'ellls) #of Wells - Soil Boring(s) #.I wnngs Geotechnical •cl woos <br /> Out-Of-Service Well - Out-Of-Service Well Renewal - Cross-Connection Repair <br /> New PUmD i/Pump Replacement Pump Repair Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth it 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 -Steel - Plastic _ Stainless Steel - Other <br /> Grout Seal Depth ft Neal Cement(9-1 Ib bag15-10 gat water) Sand Cement sack mix/7 gal water <br /> - Bentonite(20%solids) Other <br /> Grout Placement Method - Pumped Free Fall Other - Retardant/Accelerator(name) <br /> EIQLSTAL Installed By - Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width it Length it Thick In Christy Box Stove Pipe <br /> PUMP Submersible- Turbine Other HP 3 HP Pump Set 560' ft Standing Water Level 220 h <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 /> MINIMU 4 HOU NC OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE President/Owner DATE 5/18116 <br /> i 4 n,r a A <br /> Nov, <br /> p MqY 1 9 201 <br /> o 6 <br /> I ElVOgQl/l1y <br /> PA <br /> �CTyOE�� Ilyn, <br /> A[i.s�s:r�V a.m..R�r d' Y.,kT N. �� �—J - --• � <br /> prpu.e:..e., r,,.;!dot •k,es awn (A ( Y <br /> st rc i•=6C' � . <br /> l <br /> DEPA TMENTrU En&LY <br /> Application Accepted Date 7 v` Area Employee ID# vt'�V " <br /> Grout Inspection By Date ` SPECIAL Well Permit 18 <br /> Pump Inspection By Date g� _ WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#I Amount Dato Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted �-Service Re uest# <br /> a ✓r 5 Q• *Z/ <br /> WELL T1 q ELL lP,lMP PERMIT <br />