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19582 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 71 71—S.A-99 CiryaiP STOCKTON 95206 <br />CROSS STREET... UANTAS LANE APN 17 7 - 2 6 - 01 '4 PARCEL SIZE 15 5 - UND USE APPLICATION # <br />OWNERNAME SAN JOAQUIN Cb INTY GEWNERAL SAERVICES PHONE <br />OWNERADDRESS 4A N SAN TnAQTTTN ST TF 590 CITYISTATFIZIP STOCKTON 95202 <br />CONTRACTOR Delta. Pump gTnC_KTnN ARMATURF R MOTOR WORKS ff"Q._209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP Stockton, CA 95203 <br />SUBCONTRACTOR __ PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE 0 C-57 N C-61 <br />GEOGRAPHICAL INFORMATION: <br />0 D-09 0 Other <br />Coordinates X <br />Y <br />CITY/STATEIZIP <br />NUMBER 724778 ExPIRATIONDATE 0811 <br />Township Range Section <br />u u 11k;­uriivdte uAg%gaaonlHgrlcultural C Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water system Name on a ame or one Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Weff(s) # of wells D Soil Borings) # of borings <br />u Geotechnical <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />0 New Pump C Pump Replacement X7XOump Repair 0 Raise Well Casino <br /># of borings <br />Drilling Method C Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation— <br />in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Weil Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel C Plastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 Ib bag/5-10 gal water) C7 Sand Cement <br />sack mix17 gal water <br />0 Bentonite (20% solids) ❑Other ` <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />Do <br />„o� - -y a vimar ❑ rump contractor 0 Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in G Chesty Box G Stove pipe <br />PUMP ikjtubmersible0 Turbine C Other HP 40 Pump Set] -Q7 ft Standing Water Level __An 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS ee -,h cD <br />Info <br />EHD 43.06 <br />8/04/08 <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />Z/ TITLE CEO DATEZ4 7 2 0 1 7 <br />.i r1-1 <br />-29S?2 <br />RTMENT USE PNLY <br />Date <br />Date <br />Date <br />Date <br />Amount <br />Remitted <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />y <br />v, <br />Area Employee ID#Vf"f,1,0 <br />S��PECIAL Well Permit <br />WAIVER Received <br />Constructed WeIJ, Depth ft <br />Invoice # <br />Well ID# <br />WELL /PUMP PERMIT <br />