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;,7960 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVERONMENTAL HEALTH DEPARTMENT 600 E.Malo Street-STOCKION CA 95102 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JoBADDREss 7330 Delta CIIt Tracy 95304 <br /> CROSSSTREET MacArthur APN —02,0-3 PARCT.1.SIZE. 10 LANDUsEAPIWCATtoN# <br /> OWNER NAME John Pereira PHONE 481-2886 YY <br /> _ i <br /> OWNER ADDRESS 15673 W. Retiondo Dr CrrY/STATYIzIP Tract/ 95304 <br /> I <br /> CONTRACTOR Delta Punip PHONE 209-466-9625 <br /> CONTRACTIDRADDRFSs 646 S. California Street C7Tv/STATE/Zp Stockton, QA 95203 <br /> SUBCONTRACTOR - PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ' <br /> LresNsE C3 C-57 XXC-61 13 D-09 ❑Other NUMBER 724778 ExPutATIONDATE 8/08 TLk1�t�TIr <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ iC) <br /> INTENDED USE II Domcstic/Private O Irrigation/Agricultural Cl Industrial Cl Water Quality Monitoring ❑Soil Sampling/Characterization <br /> O Public Water System <br /> If diBereot from Owner: eta iacm a ontsct Nme w Phone _ <br /> TYPE,OF WORKew Well O Replacement Well ❑Well Alteration/Modification O Other <br /> O nitoring W i(s) N of wells O Soil Boring(s) s°Tb0°"a` ❑Geotechnical s otbonoge <br /> I7 Ou(-Of-Service ell ❑Out-0f-Service Well Renewal O Cross-Connection Repair <br /> X ew'Fu O Pum Re lacement O Pump Repair <br /> WELL CON UCTION <br /> 14 <br /> Drilling M b ❑Mud Rotary ❑Air Rotary O Auger ❑Cable Tool Push Point O Other <br /> Proposed I Depth R Excavation in diameter ❑Open Bottom O Gravel Pack/Gravel Size in diameter <br /> ❑C uctor Casing in diameter / Conductor Casing Depth ft <br /> Well Casin Diameter�in Thickness/Gauge/ASTM Sched O Steel O Plastic O Stainless Steel OOther <br /> Grout Stat Depth ft O Neat Cement(941b bag/J-10 gal water) O Sand Cement sack mix l 7 gal water <br /> O Benlonite(20%solids) O Manufacturer Spec%solids'_% Name O Specs on File O Specs Submitted <br /> Grout Placement Method O Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By O Driller O Pump Contractor Cl Other i <br /> O Concrete Pedestal Dimensions:Width it Lea th ftThick In ❑Christy Bos O Stove Pipe <br /> = gl Submersible O Turbine D Other HP 1 Pump Set 10 7 ft Standing Water Level 7� R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> 30AQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. !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 /> M IIMUM 24 HOUR ADVANCE NOTICE.REQUIRED FOR INSPECTIONS _�- <br /> SIGNED TITLE CEO DATE 3/08 <br /> �e <br /> 1 <br /> LA C U <br /> IR N E <br /> }{ L H <br /> —— — — tea <br /> D EPARTMENT USE NLY Q <br /> Application Accepted By f 1 Date Area Employee IDd <br /> Grout Inspection By to ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth l <br /> COMMENTS <br /> PE SC Received heckv/ Amonat Date Permit( Invoice Jtr'"� Well WO <br /> Codes Into B s Remitted Service Request N <br /> r <br /> i <br /> Ik <br />