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1112 WELL/PUMP PERMIT <br /> SAN JO:AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTO14 CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 18334 S. Mac Arthur Dr. CITYIZIP Tracy 95'304 rn <br /> D <br /> CROSS STREET Delta Ave- APN 21-302-020 PARCEL SIZE 109.86 LAND USE APPLICATION# o <br /> >o <br /> OWNER NAME Marca Bella Farms PHONE 209-321-6936 <br /> OWNER.ADDRESS 10876 Tracy Btvd. CRY/STATEJZIP Tracy.CA 95304 <br /> CONTRACTOR Delta Pump,Inc. PHONE 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S.California St. CITYISTATE/ZIP Stockton,CA 95203 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE i C-57 X C-61 D-00 Other NUMBER 1055434 EXPIRATION DATE 7/31/2021 <br /> BILLING PARTY: OWNER CONTRACTOR 1 I SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria(4391)-1 Dibromochloropropane(4392) -1 Arsenic(4393) <br /> INTENDEO USE X Domestic/Private -1 IrrigatiorLAgricultural - Industrial Water Quality Monitoring F Soil Sampling?Characterization <br /> I Public Water System <br /> If driferent from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i I New Well I Replacement Well Well Alteratio rt,Mod ification Other <br /> -1 Monitoring Well(s) #of wells - Soil Boring(s) a of borings L- Geotechnical <br /> I Out-Of-Service Well Out-Of-Seance Well Renewal Cross-Connection Repair <br /> J New Pump Pump Replacement X PUMP Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> DI filing Method -i Mud Rotary L Air Rotary U Auger U Cable Tool _ Push Point Other <br /> Proposed Well Depth ft Excavation in diameter I I Open Bottom I I Gravel Pack/Gravel Size in diameter <br /> J Conductor Casing In diameter 1 Conductor Cast rig Depth It <br /> Well Casing Diameter_ in Thick nessiGa ugeiASTM Sched I 1 Steel Plastic I Stainless Steel Other <br /> Grout Seal Depth ft _ Neat Cement(94 lb bag/5-10 gat water! _ Sand Cement sack mix!t gal water <br /> I Bentonite(20%solids) i Other <br /> Gioul Placement Method . Pumped _I Free Fall - Other L, Retardant!'Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor - Other <br /> Concrete Pedestal-1Dimensions Width ft Length ft Thick in Christy BOX a Stove Pipe <br /> Pump X Submersible. Turbine _ Other HP Pump Set If 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 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 /> IUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Tm.E CEO DATE 11/11/2020 <br /> y4 <br /> 1 777-1 <br /> I I IJ 111 11 ILL <br /> t <br /> DEPARTMENT USE ONLY y <br /> Application Accepted By �/� Date IXJG ,JZ U Area C/'1 Employee ID# <br /> Grout Inspection By / Date I SPECIAL Well Permit <br /> Pump Inspection By fan f .5C o l 9e t ^L Date (1 _ I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# <br /> Codes Info B Cash Remitted Service Request# <br /> _ 2 3 NnT <br /> 17 j <br /> ('7'r <br /> ---- -- <br /> EH043-66 6/11!1619 SAN JOAQUIN-Car KTXT <br /> -- <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />