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#8917 WELL/PUMP PERMIT <br /> SAN JOAQLIN COUNTY ENVIRONNI:EWTAL HEALTH DEPARTMEN-r 600 E.Main Street-SFOCKrON CA 95202-(209)46&3420 <br /> .NON-REFI,N-DABLEPERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES1YEAR FR03iDATE ISSLJED <br /> ,rJ . <br /> JOB ADDRESS 12650 Platti Roams CtTy/w Tracy 95304 y <br /> CROSS STREET Tracy Blvd. Apr! 212-100-03 PARCEL.SIZE`t / LAND USE A"LACA*nON 0 <br /> OWNERNAI,IE Louis & Betty Galli PHoNE 836-4046 I" <br /> OWNER ADDRESS same LI'1'ISTATE/ZIP <br /> CON-MACPOR Delta Puma moNE 209-466-9625 i <br /> I <br /> CONTRACTORADDRESS 646 S. California Street Crrv/STA-mare Stockton, CA 95203 <br /> SUBCONTRACTOR T._ PRONE <br /> SUBCONTRACTOR ADDRESS_ Crry15TATFJ7rP <br /> LicvNsE OC-57 K"aC11 12D-09 )Other NUMBER 724778 EXPMA'nONDATE 8/08 <br /> GEOGRAPIUCALINTORNtATION, Coordinates S Y Township Range Section II <br /> IN:WMD I icY. DomesticlPrivate ❑"mgation/Agricultural Cl Industrial ❑Water Quality Monitoring ❑Soil Sampling/CltatwCenzation { <br /> 0 Public Water Sysmn IIIf <br /> tf dim arc from Owner t yuua, met. e or 1 <br /> i <br /> TYPE OF WORW Cl New Well 0 Repl+:cement Well ❑Well AlterationlModifteAtion 0 Other <br /> C3 Monitoring Wells} _#Of Wells ❑SoilBoring(s) r��o-p 0 Geotechnical B of is <br /> O�VOut-Of-Service well Q Ont-Of-Scrvece Well Renewal Q Cross-CDnnectimt Repair <br /> XINow Pump ❑PuaT Re lacemrnt ❑Pump Rzpair <br /> WELT.CONSTRUCTION <br /> Drilling Method 0 Mud Rotary Cl Air Rotary 0 Auger 0 Cable Tool 0 Push Porn: 0 Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Siu it,dittmaer <br /> C Conductor Casing in diameter / Conductor Casmg Depth It { N <br /> Well Casing Diameter in ThicknessfGaugc/ASTM Schell ___- ❑Stcel C3 Plastic ZI Stainless Steel ❑Other <br /> Grout Seal Depth _ft O Near Cement{79 Ib bag/5-10 gat water) ❑Sand Cement $ack ma/7 gad water <br /> ❑Bentonite(20%solids) 0 Manufacturer Spec%solids_% Name ❑Specs on File 0 Specs Submitted G <br /> Grout Placement Method ❑Pumped 0 Fret Fall 0 Otho_ ❑Rctatdrat/Accelerator(name) r <br /> PFDFscnL Installed By 0 Driller ❑Pump Contractor Cl Other { <br /> ft"Thick in ❑Christy Bea D Stove Pipe <br /> 0 Concrete Pedntal Dimensfooc Width _a Length <br /> 62 ft Smatd ng Wnta Level 12 7 ft <br /> gl MP Mubmersble ❑Turbine C Other HP_ 1 Pump Set 7+ <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 REGUTATIONS. I ALSO CERTIFY THAT MY REQUHIED LICENSE 1S tel[ <br /> CURRENT ANDACTIVE WITH'CHS CALIFORNL4 CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS- <br /> UM <br /> AWSUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TI LE CEO DATE 12/18)07 l� <br /> I <br /> a <br /> { <br /> — - - N N <br /> �nr= <br /> ,� DEPARTMENT USE ONLY /S <br /> Application Accepted By_ w` _ Date I J[� 0 f Area _ Employee")# LLC <br /> Grout Inspection By Date Q ❑ SPECIAL Well Permit <br /> Pump lasoection By Date U ❑ WAIVER Received <br /> Constructed W Depth ft <br /> COMMENTS <br /> s <br /> PE SC Received a Amount Date Pcrmrtl Iavolce# Well 1D# <br /> Codes I.to By Cash Remitted Service nnt# <br /> 3Qv os:- z7 f 2 <br /> s� � Ilp <br />