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21029 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 96205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 11899 W Valpico Rd <br /> CtryzP Tracy 95376 m <br /> D <br /> CROs STREET C'o r r a l Hollow Rd. APN 2 4 2-0 5-0 0 3PARCEL 512E 0 . 6 8 LAND USE APPLICATION <br /> OWNER NAME William Fritche 925-422-4406 m <br /> PHONE <br /> OWNER ADDRESS Same CITYISTATE/ZIP <br /> CONTRACTOR Delta p=p S,1 nrKTnN ARMATi1Rp R MOTOR WORKS Milk.=. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE . ❑ C-57 9 C-61 0 D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/1� <br /> GEOGRAPHICAL INFORMATION: COofdinates X Y Township Range Section <br /> INTENDED USE i Domestic/Private 0 Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 SOil Sampling/Characterization <br /> XO Public Water System <br /> It different from Owner: Water ys mame ame or Flnone,Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Sorin9( )s k of borings � <br /> ❑ Geotechnical <br /> D. <br /> Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair ie® <br /> ❑ New Pum Pum Re lacement ❑ Pum Re air 0 Raise Well Casin <br /> WELL CONSTRUCTION OlJ <br /> Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other 3qN JCA Y <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel PacklGravel 0roM)1p <br /> 11 er <br /> 0 Conductor Casing in diameter I Conductor Casing Depth ft Rrme,,' <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94/b bagl5-10 gal water) 0 Sand Cement sack mixl7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br /> PUMP Q{Submersible❑ Turbine 0 Other HP 1 1 2 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. 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 /> ZIJ.J „E#QVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED i •� --''� TITLE CEO <br /> DATE <br /> r <br /> Y <br /> r 'r✓` ° Approximately 80 <br /> ft from Valpico <br /> uT .. <br /> r <br /> Rd w <br /> a <br /> r' <br /> - ra <br /> - <br /> EP RTMENT UE 9 N L Y <br /> Application Accepted By Date Area Employee IDoe� <br /> Grout Inspection By Date SPECIAL WAIT Permit <br /> Pump Inspection ByVa Date�'j�2 [ t,d, WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS It <br /> PE Sc Received ec Amount Permit/ <br /> Codes Info B ash Remitted Date Service Re uest# Invoice# Well ID# <br /> WP 0\ Z <br /> EHO 43-06 <br /> WELL/PUMP PERMIT <br />