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19980 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDARLF PFRMIT CALL (20919.53-76517 FAR INSPFr:TInNA FYPIRFS 1 Y=AP 1=anne nArG lecimn <br />JOB ADDRESS 27282 FAIROAKS RD- CITY/ZIP TRACY 95304 <br />CROSS STREET VAP I t?n APN 248-10-032 PARCEL SIZE 5 . LAND USE APPLICATION # <br />OWNER NAME ANNETTE AL ISAGAR V f� �1r PHONE 479 3695 <br />OWNER ADDRESS SAMF LA/U�yl' ) L7�1 CITY/STATE/ZIP <br />CONTRACTOR Delta Pump-sTn(, ARMATLIRF & MOTOR WORKS 11rld61. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1`$ <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE 13Amestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner: Water System Name uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification 0 Other <br />C Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings ❑ Geotechnical # ofborings_ ZVC <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair - � fn <br />❑ New Pum 0 Pum Replacement um Repair ❑ Raise Well CasingU <br />WELL CONSTRUCTION UAN <br />jV <br />Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other N �RQUi. CCU <br />D / <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size -In dtarpeter. <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped ❑ Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width It Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP XXubmersibie ❑ Turbine 0 Other HP ___�J Pump Set ft Standing Water Level ffttl <br />1 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED ' y;r.- x__�_r=.� •<-- TITLE CEO DATE <br />NOTE: <br />PUMP SET & STAND!NG WATER LEVEL <br />IS UNKNOWN UNTIL THE JOB IS DONE <br />u, <br />mm <br />D <br />0 <br />O <br />m <br />m <br />En <br />Y <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 7- Area Employee ID#&Y—W <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date L U WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />ReceivedChec <br />B <br />as <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />3a/ <br />- <br />0031 sol S <br />thu 4s-oe <br />8/04/08 WELL /PUMP PERMIT <br />