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1 9582y / WELLIPUMP PERMIT <br />SAN JOAr1UIN COUNT-( ENVIRONMENTAL HEALTii 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 />OB ADDRESS 717-'" A— 9 9 f CrTYIZIP STOCKTON 95206 <br />CROSS STREET-_ QUANTA S LANE APN 177-26-01 ry PARCEL SIZE �jQND USE APPLICATION #r <br />OWNERNAME SAN TOAQJJTN COUNTY EWNERAL SAERVICES b7'S� <br />_ PHONE <br />OWNER ADDRESS Q4 N RAN Tflg�]1Tl�J..ST- ATF 590 CITY/STATE(ZIP STOCKTON 95202 <br />CONTRACTOR ]?elta Pump gTC)CKTQ 1 ARMATf1RF u MOTOR WORxS x_209-466-96 S <br />�ONTRACTORADDRESS 646 S. California Street CITYISTATEIZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />M..-. PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE C C-57 X C-61 D D-09 ❑ Other <br />GEOGRAPHICAL INFORMATION: Coordinates x <br />CMYISTATEIZIP <br />NUMBER 724778 EXPIRATIONDATE 08/IQ <br />Y I Township Range Section INTENDED USE C Domestic/Private DX�gafion/Agricultural ❑Industrial C Water Quality Monitoring ❑ SDii Sampling/Characterization <br />❑ Public Water System <br />If different frorn Owner: a er ys em ame <br />on ac ame or one um er <br />TYPE OF WORK 0 New Well 0 Replacement Well G Well Alteration/Modification 0 Other <br />C Monitoring Wens) # Of Wells D Soil Boring(s) # of borings g of borings <br />C Out -Of -Service WellGeotechnical <br />LD Out -Of -Service Well Renewal C Cross -Connection Repair <br />G New Pump C Pump Replacement )jXPump Repair <br />WELL CONSTRUCTION ❑Raise Well Casin <br />Drilling Method C Mud Rotary C, Air Rotary 5 Auger D Cable Tool 0 Push Point 0 Other <br />Proposed Well depth ft Excavation in diameter C Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />G Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter - in Thickness/Gauge/ASTM Sehed <br />Grout Seal Depth ft <br />0 Steel 0 Plastic ❑ Stainless Steel 0 Other_____ <br />0 Neat Cement (94 lb bag/5-10 gal water <br />Bentonite (20% solidsj 0 Other ) Sand Cement sack mix17 gal water <br />Grout Placement Method 0 Pumped 0 Free Fail 0 Other <br />0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller D Pump Contractor C Other <br />C Concrete Pedestal Dimensions: Width ft Length It Thick <br />._____._,_, in 0 Christy Box ❑Stovepipe <br />PUMa §[22bmersible0 Turbine C Other HP 40 <br />Pump Sett 0 7 ft Standing Water Level^ ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />WORKERS COMPENSATION LAWS. THAT I AM IN COMPLIANCE WITH ALL <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />>IGNED �� 7 TITLE CEO <br />DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />. � " L Employee ID/11A�J/�/' L'�2 <br />SPECIAL Well Permit <br />WAIVER Received <br />Date . Constructed Well Depth <br />_ it <br />Godes I <br />ash emitted Date <br />1-71- � p00 3-7 7Z6 <br />EHD 43.06 <br />8/04!08 <br />tt <br />Invoice # <br />Well ID# <br />WELL /PUMP PERMIT <br />