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20981 <br /> WELLIPUMP 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 /> rn <br /> JOB ADDRESS 4128 T.i nnP Rd CITY/ZIP Tracy 95304 m <br /> D <br /> � � ��� o <br /> CROSS STREET Ahern APN PARCEL SIZF2 2 . 6 4 LAND USE APPLICATION# z <br /> OWNER NAME Bob Pombo /�/i�J�i r[/pi1/�(/j�G PHONE_217197121 7777 y <br /> OWNERADDRESS 3100 W, Mancuso Rd CITY/STATEIZIP Tracy 95304 <br /> CONTRACTOR Delta Pump-.qTnrxznN ARMAT iRF & MOTOR WORKS Mfik. 209-466-962 <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-57 X C-61 ❑ D-09 ❑ Other NUMBER .724778 EXPIRATION DATE 08/1� <br /> GEOGRAPHICAL INFORMATION: COof'dinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water ys em Name Contact Name or Phone Number <br /> TYPE OF WORK Cl New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Wells) #of wells ❑Soil Boring(s) #ofborr #of <br /> borings ❑ Geotechnical <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair Rr�C�e�� <br /> Pump Replacement ❑ Pump Repair 0 Raise Well Casing !! <br /> WELL CONSTRUCTION D <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other_ Sq,�, U�[7 ?nfn <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel S' FE: gQ4j CI�meter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft �'9' Ty p�nMFjyT hry <br /> U <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel ❑ Other— <br /> Grout <br /> ther_=Grout Seal Depth ft 0 Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixR—gall water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped ❑ Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br /> PUMP DCSubmersible❑ Turbine 0 Other HPC_ 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 AL#, <br /> WORKERS COMPENSATION LAWS. <br /> MINIM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED <br /> TITLE CEO DATE 1 /10/2019 <br /> 7 <br /> Aprox 100 ft from <br /> _ W Linne Rd •- <br /> ar .. <br /> a �r <br /> N%'il?ONI <br /> t)LP -ALTh <br /> 1 <br /> XPA TMENT USE N L Y <br /> Application Accepted By Date L Area Employee ID#� <br /> Grout Inspection By DVSPfEC91AL Well Permit <br /> Pump Inspection Byl S1�Q�`�(� Date (1l�X2;0\� WAIVER Received <br /> Soil Boring I spec.on By Date Constructed W 1 Depth ft <br /> COMMENTS ry <br /> PE SC Received 10 Amount Permit <br /> Codes Info B Cash emitted Date Service Re uest# Invoice# Well ID# <br /> �Ap31 1 d-(% Wf 301 v-z <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />