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_1 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT <br />WELL/PUMP PERMIT <br />1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS _ 12 SI 9_F R1riKER R..D CITY/ZIP gT-QJZ TQN Q 519 9 5 <br />CROSS STREET_ BEECT4P,13 _RD _ A�yPfN�_-0 8-9--.16 <br />9-16 - 0 3 7 -PARCEL SIZED 2 MLAND USS APPLICATION # <br />OWNER NAME-SS��r��L�Fr�i-�I'm S "" 'J�1V6t-I!fn�' I ^ PHONE 401-26A�i--- <br />OWNER ADDRESS f/?�q ICITY/STATEiZIP-TrT*fir <br />CONTRACTOR Delta PMMV—STn0XrP N ARMATIJRP & MOTOR WORKS MMQ. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE -0 8 1 <br />GEOGRAPHICAL INFORMATION: Coordinates X YTownshlo Ranne Section <br />NTENDED USE XlXlomestic/Private 0 irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water ys m contaCt Name or Plione Num5er <br />r= yr "Vff r, u 14ow "eu u Kepracement Wen 0 Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s)- # of wells 0 Soil Boring(s) # of borings ❑ Geotechnlcal <br />❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Ca <br /># of borings <br />Drilling Method ❑ Mud Rotary ❑ Air'Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation _ in diameter D Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth _ft <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 got water) ❑ Sand Cement sack m1x17 gal water <br />D Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br />0 Concrete Pedestal Dimensions: Width It Length ft Thick in ❑ Christy Box ❑ Stove 5;os�] <br />PUMP ASubmersible❑ Turbine ❑ Other HP Pump Set I l ft Stan ing Water Level .14,:72_ ft . <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WiTTk 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 .I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPE11L7iT LAWS. <br />MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED I.rr�E CEO <br />DATE `F= <br />PUMP/WELL is located on <br />the east side of the house <br />and east of the driveway <br />ur <br />m <br />m <br />D <br />v <br />0 <br />X <br />N <br />VEL <br />101 <br />Ty <br />Area=-- Employee I0#�Vj�-17 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />EP RTMENT <br />Received <br />By <br />USE NLY <br />Application Accepted By <br />I <br />--y�-�-* <br />Data <br />Invoice # <br />Grout inspection By <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By <br />wP0o31$3q <br />Date <br />COMMENTS <br />Area=-- Employee I0#�Vj�-17 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info' <br />Received <br />By <br />eck <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />wP0o31$3q <br />rmn A,4 -nn <br />0/04/06 WELL /PUMP PERMIT <br />