Laserfiche WebLink
WELL / PUMP PERMIT i <br /> A #7960 ` <br /> •SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL?i[�PARTMEN7 600 E.Mai eet-STOCK ION CA 95202 - (209)4G8�42U <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED .. <br /> 18087 MacArthur CITYIZIP Tracy 95304y <br /> JOB ADDRESS b <br /> Delta APN - <br /> CROSS STREP PARCEL SEZ£ LAND USE APPLICATION# i <br /> OWNER NAME Joe Roza 2(3�Oz*-3 PHONE 835-7736 " <br /> OWNER ADDRESS Same ATEIZIP <br /> CONTRACTOR Delta Pum PHONE'2 <br /> - - 1 <br /> 03 <br /> CONTRACTORADDRESS 646 S. California Street CITYISTATElzP Stockton A 952 <br /> SUBCONTRACTOR PRONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 )MC-61 O D-09 ❑Other _ NUMBER 724778 EXPIRATION DATE 8108 <br /> i <br /> GEOGRAPrIICAL INFORMATION: Coordinates X Y I 'Township Raoge Section p <br /> INTENDED USE M Domestic/Private ❑Irrigatiott/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization �PD <br /> " <br /> Q Public Water System. <br /> if different from Owner: Water System Munt .Contact Name or Pbone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well 0 Well Alteration/Modification ❑Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) N of borings ❑Geotechnical N of borings <br /> ❑Out-OMervice Well 0 Out-Of-Service Well Renewal Q Cross-Connection Repair <br /> ID New Pump 0 PuMp Re Iacetnent ❑Pump Re air <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Too] C]Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack!Gravel Size in diameter <br /> 0 Conductor Casing- ^in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 17 Steel Cl Plastic O Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bag/5-I0 gal wafer) ❑Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 0 Specs on File ❑Specs Submitted <br /> Grout Placement Method 0 Pumped ❑Free Fall ❑Other O Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller M Pump Contractor 0 Other <br /> Q Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Boz ❑Stove Pipe <br /> IPi Mp M Submersible ❑Turbine ❑Other HP 3 - Pump Set 1 Q 8 - R Standing Water Level 8 ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARES) 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 /> IMUM 24 HOUR ADVANCE NOTICE: REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 3/08 <br /> N C UN <br /> V p M-N <br /> LS <br /> ZD <br /> EPARTMENT U'fS E ONLY <br /> Application Accepted B Date Area Employee ID# <br /> Grout Inspection By _ ❑ SPECIAL Well Permit <br /> Pump Inspection By ate Jr ❑ WAIVER Received <br /> Constructed Well <br /> ft— <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well 1D# <br /> Codes Info By Cash Remitted Service Reg nest# <br /> G s 1 6 � i g � 310 05 <br />