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vS`I 7 . WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 27282 FAIROAKS RD CITY/ZIP TRACY 95304 <br />CROSS STRF-L•-r _ VAL��OB— AP'N 2 4 8 -1 0 - 0 3 2 PARCEL SIZE 5 --9-AND USE APPLICATION ## <br />OWNERNAME � SSC' « PHONE 479 3695 <br />OWNER ADDRESS q A MF _,209-4�66-7�CITY/STATE/ZIP„:ar) 6O2[5& <br />CONTRACTOR ARMATURER MOTQR <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP_. Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 X C-61 ❑ D-09 ❑Other <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />CITY/STATE/ZIP <br />NUMBER 724778 EXPtRATIONDATE Q8/1 <br />Y Township Range Section <br />uXLX,mesacrrrrvate a irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑'Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: vvzneryS(0n1 Narne 0555m Name or None NUmber <br />1 YPE OF WORK ❑ Now Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other <br />❑ Monitoring Weli(s) # of wells G Soil Borings) ofborings # of borings <br />11 Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />C. New Pump C.,.Pump Replacement ;�)eump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary C Air Rotary 0 Auger 0 Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom D Gravel PaclVGravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seat Depth ft ❑ Neat Cement (94 (b bag/5-10 gat water) 0 Sand Cement sack mix17 gal water <br />Cl Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped 0 Free Fail ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedesta) Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Mjbmersible0 Turbine 0 Other <br />HP _ 1 Pump Set ft Standing Water Level ft <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. l 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO DATE 7 <br />—_ <br />OEP <br />RTMENT SE ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />PESC <br />Received Check#! Amount <br />s Info <br />8 ash miffed <br />Date <br />I� <br />A <br />v <br />a <br />m <br />m <br />a <br />Area Employee ID# Azwrsp <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />� i A <br />Invoice # <br />Well ID# <br />ft <br />EHD 4390 <br />8/04/08 <br />WELL /PUMP PERMIT <br />