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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENV1AuNMEN'rAL HEALTH DEPARTF aua 1113033 600 E.Mato Street-STO&MN CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jog ADDRESS T Road� C1TY/Z� Tracy <br /> CROSS STREET Highway 33 APN �' PARCELsIZ[ `� 1.ANb USE APPLICATION/ l� <br /> OWNERNA?aK 'Lombardi FarmlF, ..,,"� �Q ��yyy / �N� PHONE 649-6147 41" I <br /> OWNER ADDRESS 16998 Gawne Road Crry/STATER.iP Stockton, CA 95215 <br /> CONTRACTOR Delta Pump PHONE 209-466-9625/raj <br /> CONTRACTORADDRESS 646 S, California Street crlY/STATErur Stockton, CA 95203 <br /> i <br /> SUBCONTRACTOR PHONE <br /> 4 SUBCONTRACTOR ADDRESS CrrY/STATErzJP 1 <br /> LICENSE 0C-57 XXC-61 0D-09 ❑Other NUIHEER 724778 ExPIRAMONDATE 08/12. <br /> GEoGRAPaiCALINFoRmAnoN: Coordi c X Y Towosblp Rsoge Seedon <br /> INTENDED USE Cl Domestic/Private 13 gation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charaetmiution <br /> ❑Publio Water Syysstt <br /> If ditierem from Oweer Witt Sy`McnAwe ame«PhoocN—b. <br /> I <br /> TYPE OF WoRx Q New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s)_#of wells ❑Soil Boring(g) s of bonass ❑-Gioot icai s ofborfaas <br /> ❑Out-Of-Scryico Well ❑Out-Of--Service Well Renewal Connection Repar <br /> ❑PReIaceet ❑ uRc Pull. uminstall sand se era <br /> ❑NewPum s ���—--- <br /> I�WELL CoNsTitycrioN <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger p Cable Tool ❑Push Point ❑Other (D <br /> I Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size In diameter <br /> Ili t ❑Cmductor Casing in diameter / Conductor Casing Depth A <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schell ❑Steel ❑Plastic ❑Stainless Steel O Other /'/� <br /> Grout Seal Depth It ❑Neat Cement(9I(b bog/5-10gal water) ❑Sand Cement sack mix/7 gal water V J <br /> t ❑Bentonite(20'A solids) ❑Manufacturer Spec X solid, Yo Name ❑Specs on File ❑Specs Submitted <br /> Groot Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) j 7� <br /> PEDrSTAL Installed By ❑Driller ❑Pump Contractor O Other I C) <br /> ❑Concrete Pedestal Dimensions:Width R Len fl Thick in ❑Christy Bos ❑Stove Pipe (� <br /> E3Submersible M Turbine ❑Other HP 125 Pump Sol 280 ft standin Water Level 6 2 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> S1ctvED Tint CEO DATE 04/22/11 <br /> I� <br /> 1 <br /> I <br /> t <br /> I(E <br /> Jul ijIl <br /> IAN C <br /> :NT <br /> DE_ PART_MEN_T/, UBE—ON—LY—­ <br /> Application Apled By - _ Date '( / Arco Employee lDk <br /> Grout InspeUion By / Date ❑ SPECIAL Well Permit <br /> Pump Inspection By .alis Detc 6 O WAIVER Received <br /> OF <br /> Constructed Well Depth ft <br /> COMMENTS � <br /> i PE SC Reetivtd 'Che-ow Amount Date Permit/ Invoice Well ID# <br /> ik Codes Info B o, ash Remitted Service Request N <br /> t-Z -71 g <br /> I <br />