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r 9 18535 WELL/PUMP PERMIT JOAQUIN COUNTY ENVIRONMENTAL HEALTFI DEPT 1868 East Hazelton Avenue: - STOCKTON CA 95205.6232 - (209) 468.3420 ,,I -REFUNDABLE PERMIT CAIJ, (209) 953.7697 FOR 6N8,Pl CTION8 EXPIRPI; 1 YFAp r-pnnn nATr- 15�IIFn :REBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ;,ZUIN COUNTY ORDINANCES, -STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS a;I.IN'I' AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT .I AM IN COMPLIANCE WITH ALL �14ERS COMPENSATION LAWS, I�i11E11(tB.9. �? 9-10LIR ALWAI\ CE NOTICE', E', 6`a!;:Qf.lPl I,3:F 5-:OGe. IWSPECTIO: NS TITLE CEO DATE 6 / �? / 2 0 6 1 a PUMP/WELL is located approx. 1,319.89 Duncan Rd x� 2016 v��E! /�RTMENT U E 0 LY Application Accepted B Y� ..,� //,.� Date Grout Inspection By _ Date Pump Inspection By Date le Soil Boring Inspection By Date AMENTS 'IENTAL HEALTH P ITKSERVICES 0 yDDRESS 17814 E. COPPERROPOLIS RD. CITY/ZIP STOCKTON 95215 (Ti Amount Remitted Date IS STREET DUNCAN RD. APN 183-20-006 PARCEL SIZE 5 5 LAND USE APPLICATION # n N - m IRNAME TRIPLE S FARMS PHONE 209 969-4889 N LR ADDRESS P BOX is CITY/STATE/ZIP FARMINGTON CA WAIVER Received n:ACToIe Delta Pump_4T(1C'KTQN ARMATURF MOTOR WORKS 1"Ch. 209-466-9625 Constructed Well Depth ,YACTORADDRESs 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 iNpo031'b3$ ;ONTRACTOR P110NE ;ONTRACTOR ADDRESS CITY/STATE/ZIP _SE 0 C-57 XC -61 ❑ D-09 0 Other NUM13ER 724778 EXPIRATIONDA7E 08/16 .,RAFHICAL INFORMATION: Coordinates X Y Township Range Section ,L2 LP —Us r ❑ Domestic/Private )trrigatlon/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization 0 Public Water System If different from Owner: a er ys em ame on ac ame or gone um er OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification 0 Other 0 Monitoring Wells) # of wells 0 Soil Borin9() s t/ of borings ❑Geotechnical /1 of borings ❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair 0 New Pump ❑ Pump Replacement (Bump Repair 0 Raise Well Casing CONSTRUCTION ng Method ❑ Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other ,osod Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PaCIVGravel Size in diameter ❑ Conductor Casing , in diameter / Conductor Casing Depth ft �,I1 Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel D Plastic 0 Stainless Steel 0 Other rout Seal Depth ft 0 Neat Cement (94 lb brag/5-10 gal water) 0 Sand Cement sack m1x/7 gal water 0 Bentonite (20% solids) 0 Other it Placement Method 0 Pumped D Free Fall ❑ Other ❑ Retardant / Accelerator (name) _ ;STAL Installed By 0 Driller ❑ Pump Contractor 0 Other 0 Concrete Pedestal Dimensions: Width ft Length ft Thick In ❑Christy Box ❑Stove Pipe ❑ Submersible L3arbine ❑ Other HPC Pump Set 1 d n ft Stand ing,:Water Level 1 3 ft :REBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ;,ZUIN COUNTY ORDINANCES, -STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS a;I.IN'I' AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT .I AM IN COMPLIANCE WITH ALL �14ERS COMPENSATION LAWS, I�i11E11(tB.9. �? 9-10LIR ALWAI\ CE NOTICE', E', 6`a!;:Qf.lPl I,3:F 5-:OGe. IWSPECTIO: NS TITLE CEO DATE 6 / �? / 2 0 6 1 a PUMP/WELL is located approx. 1,319.89 Duncan Rd x� 2016 v��E! /�RTMENT U E 0 LY Application Accepted B Y� ..,� //,.� Date Grout Inspection By _ Date Pump Inspection By Date le Soil Boring Inspection By Date AMENTS 'IENTAL HEALTH P ITKSERVICES des SC Info Received B Check,#/ Amount Remitted Date Permit/ Service Re uest ta 7- ,4 �3 Pm, ., �' ✓ � Q(/,/A, rtiaF MEyr�A�Y Areae�laT Employee ID#_�Tt�y� SPECIAL We!I Perrrt!t �?G7s WAIVER Received 23 its Constructed Well Depth �ft des SC Info Received B Check,#/ Amount Remitted Date Permit/ Service Re uest ta Involve # Well ID/6 �?G7s a' 3- 23 its Epo-75oq iNpo031'b3$ ;8"" WELL /PUMP PERMIT