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19752 WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95206.6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />IJosADRESS 961CRIT-GIS—moi- CITYrzIPTRACY 95304 m <br />CROSS STREET KAPN 241 — 1 1 —034 PARCEL SiZE1�j gArp USE APPLICATfON )X Cy <br />OWNER NAME FRANK CAST m <br />PHONE 481 3886 N <br />OWNER ADDRESS SAME CITYISTATEiZIP <br />CONTRACTOR Delta Pump 4AT — - rnmm�a P1tS id" . 209-466-262-5 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATFJZiP Stockton, CA 95243 _ <br />SUBCONTRACTOR <br />--" PHONE <br />ADoREss <br />LICENSE O C-57 N C-61 O D-09 0 Other <br />CITY iST A, r rJZ\P <br />NUMBER 72477$ EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y Township Range Section <br />INTENDED USE �f3h�Domestic/Private 0 irrigation/Agricultural G industrial � Water Quaiity Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />tf different from Owner: a er p vn ame <br />on ac ame or one um er <br />'TYPE OF WORK 0 New Well J Replacement WeH G Well Alteration/Modification 0 Other <br />G Monitoring Well(S) # of welts L Soil Borings)# of borings # or borings <br />Our -Of -Service Well , G Geotechnical <br />Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />0 New PUMP C Pumn Ranlnr.m i .-- n.._-_ <br />Drilling Method C Mud Rotary Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well DeP th in diameter 0 Open Bottom ft Excavation p 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 />( <br />Grout Seal De th 0 Steel 0 Plastic ❑Stainless Steel 0 Other <br />P ft C. Neat Cement (94 ib bag/5-10 gal water) J Sand Cement <br />1 ` Bentonite (20% solids) D Other sack mixR gal water <br />IGrout Placement Method 0 Pumped 11 Free Fall 0 Other0 I <br />Retardant /Accelerator (name) <br />PEDESTAL installed By 0 Driller 3 Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Len th <br />g ft Thick in0 Christy Box0 Stove Pipe <br />PUMP Submersible0 Turbine G Other_ <br />HP Pump Set__ _1 _ ft Standing Water Level 1 <br />_ 1 rt <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 1 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM iN COMPLIANCE WITH ALL <br />WORKERS COMPENSATIO <br />MINIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / <br />JIGNED TITLE CEO <br />I DATE8/17/2017 <br />U E NLY <br />Application Accepted SJ�DLEARTMENT <br />' <br />y l <br />Grout Inspection By A4(&tm) Date <br />Date <br />Pump Inspection By <br />Soil Boring inspection By Date <br />COMMENTS Date <br />ved <br />EHD 43.06 <br />8/04/08 <br />e' <br />Date <br />AToa I Employee iD#, —1L—V <br />SPECIAL Weil Permit <br />WAIVER Received <br />Constructed Well Depth <br />invoice # <br />Well ID# <br />WELL /PUMP PERMIT <br />ft <br />