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�I <br />r 19756 WELL/PUMP PERMIT <br />JP <br />AN 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 />JosAooRESs 5748 E. ST. RT. 4 CITY2IP STOCKTON 95215 <br />I <br />CROSS STREET WA T,KF.R APN 1 79-23—()l 1 PARCEL SIZES 6 _ 4 3 -ANO USE APPLICATION # <br />OWNER NAME _,TRR SANGUINETTI / Gly"' 04-L tic_ pHONe209 607 9229 <br />OWNER ADDRESS 1 8 6 3 8 E. COPPEROPOLI S RD.9 (-Ci kr ��C,;' N1 u r -r I -c - i 4, Z <br />'� /9TATE/ZIP LINDEN CA 9523 <br />CONTRACTOR Delta PUMP—STOCKTON ARMA URF X MOTOR WC)RKS MU1. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE 0 C-57 X C-61 <br />GEOGRAPHICAL INFORMATION: <br />0 D-09 0 Other <br />Coordinates X <br />Y <br />CITYISTATEIZIP <br />NUMBER 724778 EXPIRATIONDATE_ 08/11 <br />Township Range__ Section <br />w111wbuwrnvare MTgauon/Agricultural C Industrial C Water Quality Monitoring 0 Soil Sampling/Characterization <br />C Public Water System <br />If different from Ovmer. Water ys em ame <br />n a ame or PnOne NUmber <br />i rrtUF WORK C New Well 0 Replacement Well u^ Well Alteration/Modification 0 Other <br />O Monitoring Welf(s) # of wells C Soil Boring(s) # of bonngs <br />C Out -Of -Service Well -� C Geotechnical <br />L, Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />C New Pump C Pump Replacement rkl)bmn RPnair - .. . <br /># or borings <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter 1 <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched <br />D Steel D Plastic 0 Stainless Steel 0 Other <br />I Grout Sea[ Depth ft D Neat Cement (94 Ib bag 5-10 gal water) Sand Cement <br />Bentonite (20% solids) O Other sack mixl7 gal water <br />Grout Placement Method 0 Pumped ii Free Fall 0 Other <br />0 Retardant /Accelerator (name) <br />PEDESTAL Installed By 0 Driller �j Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in 0 Christy Box 0 Stove Pipe <br />PUMP 0 Submersible C} Xrbine C Other <br />HP 1 0 0 Pump Set_ l g D ft Standing Water Leve! (t <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I <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 TH <br />WORKERS COMPENSATI AT ! AM IN COMPLIANCE WITH ALL <br />MIN! UiV124 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO 8/15/2017 <br />DATE <br />PUMP/WELL Is located approx. <br />73.73 ft. from the building in <br />amongst the trees <br />:MY <br />. J <br />EPA RT USE ONLY <br />Apptigtion Accepted Sy <br />D. <br />Grout Inspection By <br />Date <br />Pump Inspection By / Date (� <br />Soil Boring Inspection By <br />COMMENTS Date <br />Amour <br />Codes I Info Received he <br />D ash <br />tte <br />�174f -�3' <br />EHD 43.06 <br />8/04/08 <br />k <br />Aroa /CI Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Date Permit/ <br />Service Re zuecit # Invoice # Well ID# <br />�IWPd(D 37) 5 <br />WELL /PUMP PERMIT <br />W <br />Im <br />A <br />D <br />O <br />M <br />N <br />