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y/ �� ihal Scan <br /> 18274 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPEGTIONii EXPIRES 1 YEAR FROM DATE ISSUED <br /> 0 <br /> IJOBADDRESS 754 W_ RnWMAN RD CITY/ZIPFgFN('-14 ('AMP 952-11 n <br /> CROSS STREET LOCKHART APN 193-26-029 <br /> p99 3-2 6-0 2 9 PARCEL SIZID_ 4 6 LAND USE APPLICATION# m <br /> Cn <br /> OWNER NAME C �'tw� �tZ �� Wu�.�����,N-0- �C.lCLt,�G�- PHONE_209 640-2170 <br /> et Y-7 3� <br /> OWNER ADDRESS P. r Z &-6 QWr/ CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump-STC1(,_KTo N ARMATURE & MOTOR WORKS MD­ 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE 0 C-57 X C-61 0 D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1r-, <br /> GEOGRAPHICAL INFORMATION: Coordinate X Y Township Range Section <br /> INTENDED USE ❑ DAIXestic/Private 0 Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other <br /> ❑ Monitoring Wells) #of wells 0 Soil Boring(s) #of borings 0 Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement !RjEump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ElOpen Bottom ❑ Gravel PaCIVGravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP 3 Pump Set ft Standing.,Water Level 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE ViITi i THE CALIFORNIA CONTRACT ORS STATE LICENSE BOARD AND 1 HAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> a` 24 HOUR ADVANCE: NO'T'ICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 3/33/2016 <br /> l <br /> HOUSE <br /> W.BOWAN RD. <br /> i <br /> r <br /> PUMP/WELL is <br /> located right S <br /> ., <br /> behind the V'r, <br /> t, <br /> garage. Ep <br /> 016 <br /> s� f/ fE4LTiy <br /> DEPARTMENT US J0NLY �rNDFPA'�w, <br /> Application Accepted By_ e�t' Date t l� Area �� Employee ID# l �,7,tqV"" <br /> Grout Inspection By Date rr� SPECIAL Well Permit <br /> Pump Inspection By NN 1il Ct.,.I j l0 Date V, �1 WAIVER Received <br /> Soil Boring lnspecBy Date Constructed Well Depth ft <br /> Ion <br /> COMMENTS Tj�3�l 1rf'uNix G U D LLL- C S lf-a N-c LyLc n 1 6 .I <br /> t 5 vr.,L, <br /> PE SC Received heck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> T'%2 O5 dtl& 2,2— '73�' � 3l-fb Vc)u7H515 <br /> 81044V <br /> /08 06 L„W{r�l� 4o ff11y�1 II11 o - "\" r`.7 _A Q 1 ��" <br /> p 1•-� WELL/PUMP PERMIT <br />