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t <br /> r • i 18700 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 /> •S. <br /> JOB ADDRESS 14201' <br /> 4 2 01 VON SOSTEPV �`�`. CITYIzIP TRACY 95304 D <br /> 0 <br /> CROSS STREET BYRON RD. APN 209-27-015 PARCEL SIZE 2 4 -8 04ND USE APPLICATION# <br /> m <br /> Cn <br /> OWNERNAME R&T FARMS PHONE408 391 8401 " <br /> OWNER ADDRESS 488 PAC�OSA WAY CITY/STATE/ZIP FREMONT CA 94539 <br /> CONTRACTOR Delta Pump_STnC?KTnN ARMATURE & MOTOR WORKS ff"Q. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITYISTATEIZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE _ <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 XC-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATIONDATE 08/tj <br /> G_ _1.•1rnRPACTInA1' x Y Township Range Section <br /> INTENDED USE X)})omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> # 4RI, <br /> of borings❑ Monitoring Well(s) #of wells ❑ Sp 6Geote�aI <br /> l ir❑ Out-Of-Service Well ❑ pq❑ New Pum Pum Replacement ❑ Pum air �i3p! <br /> WELL CONSTRUCTION f ermit may have ex 'red without ECENED <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ � e o�jlp�� Push Pointp�q Other <br /> Proposed Well Depth ft Excavation 7,R,;10 WPb cp `�tl4t r[� UGravel Size s ft eter <br /> ❑ Conductor Casing in diameter / C &VOo menHealthislon EhV7,y OrN �U <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel gE M_ FM;,� <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack'mlN? water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method D Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other TRT PUMBP� Pump Set_4 0 ft Stanging Water Level 9 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. 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 /> 1111 111U 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE�7/2 01 6 <br /> PUMP/WELL is located approx. <br /> 133 ft.from the road. See insert <br /> RE C <br /> _. . " <br /> : P9 <br /> ENVIRONMENTp,1 <br /> d .ERM;T./3ERVl0 C ~ <br /> s <br /> Application Accepted 13�1=_i� Employee ID# ~~� <br /> Date SPECIAL Well Permit <br /> Pump Inspection By DateWAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS_�1Z1 17 Duma h2nOr -9PI4, y,4 (2tl ( )(/2' i� I{ r c�i k use dht� <br /> cl <br /> -c JtA <br /> PE SC Received Check#) Amount Date Permit/ <br /> Codes I Info I By Cash C Remitted Service Re uest# Invoice# Well ID# <br /> Q -75 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04,08 <br />