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18814 <br />` I.,N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT <br />Lrv�w� Stcn �t�l(;- l6 VIA-\ <br />WELL/PUMP PERMIT <br />1868 East Hazelton Avenue -STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT t;AL.L (ZUU) U06 -/6y7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 702 N. AURORA ST/ CITY/ZIP STOCKTON 95202 <br />CROSS STREET (`oRNPR nP (-.RANT 1 -AC)-9] —()QR PARCEL SIZEj 0 � *17D USE APPLICATION # <br />OWNER NAME PHONE29483 7438 <br />OWNERADDRESs 3255 W. MARCH LANE CITY/STATE/ZIPSTOCKTON 95219 <br />CONTRACTOR Delta Pump _.q'PnrKTON ARMA,-PURE & MOTOR WORKS 11"Q. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 X C-61 <br />❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 724778 EXPIRATION DATE 08/ <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE ❑ Domestic/Private kkrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water 6ystem Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />u ivew Turn u t-uinp me lacemem An-ump Ke air u Raise Well Uasin <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ 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 ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller U Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP IXXubmersible❑ Turbine ❑ Other HP ­5Pump Set ft Standing Water Level —A-()-_ 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT] AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / <br />TITLE CEO DATE <br />DEPARTMENT USE ONLY <br />Date _31 <br />Date <br />Date <br />Date <br />T <br />D <br />0 <br />0 <br />A <br />m <br />in <br />Jj �� <br />Zai:h <br />n U'-PARTMENT' <br />Area O Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Sc <br />Info <br />ReceivedCheck <br />B <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />4-280) <br />52012757 6 <br />f6011v55 <br />EHD 43-06 <br />8/04/08 WELL /PUMP PERMIT <br />