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20131 3 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN-KEFUNDABLE PERM <br />GALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 'T ' ACAMPO RD . CITY/Zip T.nr) T c A 95242 <br />CROSS STREET THORNTON RD. APNfill - y� PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME DPSNAYP.R PIAIRy , •/ Il � PHONE 712-7482 <br />OWNER ADDRESS 20243 N. ROND . RD - T,OD T ('A ()-,242 CITY/STATE/ZIP <br />CONTRACTOR Delta Pump_,TC)(-KTnN ARMATljgp R MOTOR WORKS WtttQ. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />(SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 X C-61 0 D-09 ❑ <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />CITY/STATE/ZIP <br />NUMBER 724778 EXPIRATION <br />Township <br />DATE 08/t% <br />Ranqe Section <br />NTENDED USE GXDAInestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 0 Soil Sampling/CharKt�rgtion <br />C Public Waters stem <br />If different from Owner. Water System ame Contact or u U f <br />rVPF t)r Wnpv r Naw Wall n r?anlanan,a.,+%A/11 n 1A1 11 Au,....i:,._ie._�:a__.:__ <br />0 Monitoring Wells) # of wells ❑ Soil Boring(s) V4 Vµ v # of borings G' 0 Geotechnical <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair [UB� <br />❑ New Pum mp Replacement 0 Pump Repair 0 Raise Well Casing SAN JOAQUIN C <br />ot lftmj <br />WELL CONSTRUCTION WEALTH <br />Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other DEPARTMENT <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft Q Neat Cement (94 lb bag/5-10 gat water) 0 Sand Cement sack mixR gal water <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP 909bmersibleD Turbine 0 Other HP 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE VI(LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO <br />DATE2/6/2018 <br />DE ARTMENT U E JONLY <br />Application Accepted By Date <br />Grout Inspection By Date_ , <br />Pump Inspection By t Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area_��� Employee ID#&T' <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 />Che <br />Amount <br />Remitted <br />Date <br />permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />2112113',CI'L,- <br />8/04!08 WELL /PUMP PERMIT <br />V1 <br />mm <br />D <br />0 <br />CT <br />In <br />In <br />N <br />