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I �, FIWELL/PUMP PERMIT SAN JowQU7N COUNTY ENyfBTjNMENTAl EAL7H DEtARTM1iETIT �� CICIO 13033 �0 B.M+lo Street-S7ON CA 95201 -(209)468-3420 I NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED Jog ADDRESS DUrh--+---r Road CyTyIZIP Tracy CROSS STREET Highway 33 APN ` PARCEL S=--aFl.ArtD USL ArPLICATIon N OWNERNAME Lombardi Farms4,;�._ ,,rPPHONE 649-6147 f''r L2S� OWNER ADDRYiSS 16998 Gawne Road CTrv/STATrJZID_ Stockton, CA 95215 CONTRACTOR Delta Pump PBoNE 209-466-9625 ' S' CONTRACTORADiwss 646 S. California Street Crry/STATE/Zrr Stockton, CA 95203 SUBCONTRACTOR PHONE SUICON RACIOR ADDRESS Crry/STATrJZrr ' UCENSE 0C-57 XXC-61 [3 D-09 ❑Oihar NUMBER 724778 EXPtRA'nONDATE 08/12 GEOGRAPHICAL LhTORMA77ON: Coord!R X Y Township Range Section ItEnEED Usx ❑Domestic/Private I gation/Agriculturral ❑Industrial ❑Wattr Quality Monitoring ❑Soil Sarnpling/Charactorization ❑Public Water S tl diHacvt froo C �F•ta 3ywem Fin• C..tWtN—._n_-CNuesba I TYPE Or WORx ❑New Well ❑Replacement Well ❑Well Altcration/Modification O Other 1 ❑Monitoring Well(s) N of wells - ❑Soil Boring(s) a of banaV fRc__�_,__] s of boruw J_ ❑Out-0f-Serviw Well E3Out-Of--Service Well Renewal ss-Connection Repau ❑New Pum OP Re laccmrnt ❑Pu Repair Pull u install sand se era W ELL Q2NSTRL,CTtON Drilling Metbod ❑Mud Rotary ❑Air Rotary ❑Auger Q Cable Tooi ❑Pusb Point ❑Other �1 Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size la diametar V ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter In Thlckness/Gau&c/ASTM Sched O Steel O Plastic O Stainless Steel ❑Other Grout Seal Depth tt ❑Nat Cement(941b bag/5.l0 ga/water) ❑Sand Cement sack mus 17 0 water V J ❑Bentonite(2056 solids) ❑Manufacturer Spa K solids_% Namc ❑Specs on File ❑Spew Submitted h Croat Placement Melbod O Pumped ❑Fra Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Instilled By ❑Driller ❑PUMP CDmnctor ❑ Other ❑Canerett Pedestal Dimensions:Wldtb R Length R Tbiek in ❑Christy Bos ❑Slave Pipe (n py>Q ❑Submersible MTurbina ❑Other HP 12�_PuruSet 280 itStanding Waterl-evel___62 11 I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND TRAT THE WORK WILL BE DONE IN ACCORDANCE WITS SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNER TITLE CEO DATE 04/22111 I7j 11' PAN NARN f I i i� PLC EIVE L' ' AN CA.-L-IC�Iwr I• F.[ - D E P A R T M E.N T U S E_fLN.L_YJ - -�.^:_ -ter.•--+�:c-sem:" '°-' Applicalion A pled By - '- '7�'^— `Duei�' Area Employee IDN�oss Grout Inspection By Date C) SPECIAL Well Permit Pump Inspection By_ Dale C3 WAIVER Received Constructed Well Deplb !t COMMENTS PE Sc Received a Amount Date Permill Iovolce0 Well IDN i Codes Into By b Remitted Service Request N `ll l 52o L� -71 I