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r . 1► , S1653 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 T YEAR FROM DATE ISSUED <br />JOBAODRESs 8499 _ JACK TONE RD CITY/ZIP STOCKTON 95215 <br />CROSS STREET F_ MARIPOSA R n _ APN 1 81 -1 7 - 0 0 8 PARCEL s12E1 16 . 524N0 USE APPLICATION <br />OWNER NAME THOMP SON RANCH �CK/ PHONE 639-1583 <br />OWNER ADDRESS 7603 JACK TONE RD. CITY/STATEIZIPSTOCK TON CA 95215 <br />CONTRACTOR Delta Puma STOICKTON AR ATTIRE A MOTOR WORKS 209-466-9625 <br />CONTRACTORADDRESs 646 S. California Street CITYISTATEIZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />-"-"' PHONE <br />iSUBCONTRACTOR ADDRESS C1TY(STATEIZIP t <br />LICENSE D C-57 X C-61 O D-09 O Other NUMBER 72478 EXPIRATION DATE 0813 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Township Range Section <br />INTENDED USE❑ Domestic/Private XXrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: a er ys em Name <br />MW ame or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />D Monitoring Wells) # Of wells D Soil Boring(s)# of borings # of borings <br />-, <br />Out -Of -Service Well � Geotechnical <br />L Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />O New Pump C Pump Replacement XX Pump Re air 0 Raise Well Casing <br />NELL CONSTRUCTION <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 in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter —in Thickness/Gauge/ASTM Sched <br />O Steel ❑Plastic O Stainless Steel ❑Other <br />Grout Seal Depth It 0 Neat Cement (94 Ib bag/5-10al water) ) Sand Cement sack mW7 gal water i <br />`: Bentonite (20% solids) ❑Other <br />Grout Placement Method 0 Pumped ❑ Free Fall 0 Other <br />❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By D Driller ❑ Pump Contractor O Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in O Christy Box 0 Stove Pipe <br />PUMP SubmersiblVL-Al urbine 0 Other HP Pump Sett Q n ft Standing Water LeveAra 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. <br />CURRENT AND ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />ACT WITH CALIFORNIACACONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSA N LAWS. <br />MINIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />31GNEb TITLE CEO <br />DATE7/31 /201 7 <br />I <br />EP RTMENT U E ONLY <br />Application Accepted By � Date <br />Grout Inspection By _ <br />Date_W_17__ <br />Pump Inspection By / a <br />Date <br />Soil Boring Inspection By <br />COMMENTS Date <br />•_� �.necK�F/ I Amount <br />t3 C/ast ,jR.mmitted <br />EHD 43.06 <br />8104108 <br />U <br />T <br />m <br />D <br />0 <br />0 <br />X <br />m <br />ti <br />Aroa — Employee [DO <br />SPECIAL Well Permit —�"�-/e1vr <br />WAIVER Received <br />Constructed Well Depth AUG p 2017 <br />S <br />— B1yV Cp�N1Y <br />Invoice # 1 Well <br />WELL /PUMP PERMIT <br />