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~� 18999 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT <br />WELL/PUMP PERMIT <br />1868 East Hazelton Avenue - STOCKTON CA 95205.6232 - (209) 468.3420 <br />NUN-KEFUNDABLE PERMIT GALL LU`U yS:S-!Gy! FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Received <br />B <br />�} <br />F_ <br />Amount <br />Remitted <br />Date <br />JOB ADDRESS 334 <br />.TAIANT RD- <br />CITY/ZIPACAMpn <br />A5220 <br />o� <br />CROSS STREET HWY <br />99 APN 005-17-003 <br />PARCEL SIZE _LAND UseAPPL(CATION # <br />OWNER NAME TONY <br />1r U,5 AAV1 D Tib t <br />-��j <br />TMA Tr_ �_AL <br />PHONE 209 607 366 b <br />I <br />OWNER ADDRESS <br />E ACAMPC) Rn <br />CITY/STATE/ZIP ACAMPQ <br />CA—Q 5 2 2 0 <br />CONTRACTOR <br />Delta Pump-.qTnrKTnN ARMATiiRE <br />& MOTOR WORKS <br />MOI>=_209-466-9625 <br />CONTRACTOR ADDRESS <br />646 S. California Street <br />CITY/STATEIZIP <br />Stockton, CA 95203 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 ilii C-61 <br />0 D-09 ❑ Other. <br />CITY/STATEIZIP <br />NUMBER 724778 EXPIRATIONDATE 08/fl <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE ❑ Domestic/Private OXIIXigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 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 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />D Monitoring Weil(s) # of wells ❑ Soil Boring(s) # of borings 0 Geotechnical # of boriRE EN7 <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal 0 Cross -Connection Repair CE�VEp <br />0 New Pump 0 Pump Replacement Xkump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air'Rotary ❑ Auger 0 Cable Tool ❑ Push Point ❑ Other s_4 °gourN <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size "irl"nf� <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 ❑ Neat Cement (94 lb bag/5-10 gal wafer) 0 Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe <br />PUMP XWubmersibleo Turbine ❑ Other HP -Q_ Pump Set 1 2 6 ft Stan ing Water Level g r, 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 A CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT .I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPE ATION LAWS. <br />SIGNED <br />Application Accepted Bq� <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />ARTMENT USE ONLY <br />Date <br />Date <br />Date <br />Date <br />Areae Employee ID#,�o <br />SPECIAL Well Permit <br />WAIVER Received <br />ft <br />T <br />m <br />D <br />0 <br />0 <br />A <br />m <br />N <br />1H <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />(-Checw <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />38z <br />o� <br />db <br />� Zq <br />S�,007m31 � <br />Wpvo3���c� <br />EHD 43-06 <br />8/04/08 WELL /PUMP PERMIT <br />