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19001 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT WELL/PUMP PERMIT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468.3420 NUN-KEFUNDABLE VERMIT LeALL tGUy) V0:3-ttiy( FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 3-0-18 F.- TA4ANT Pr)- CITY/ZIP ACAM20 95220 CROSS STREET HWY 99 APN ()05-1 7-021 PARCEL SIZE 1 F, S SAND USE APPLICATION # OWNER NAME OWNER ADDRESS PHONE 209 697 3665 CITY/STATE/ZIP ACAMPO CA 95220 CONTRACTOR Delta Pump _,qTp(,.KTnN ARMATURR & MOTOR WORKS M*Gh. 209-466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP Stockton, CA 95203 SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE ❑ C-57 TA C-61 ❑ D-09 PHONE CITY/STATE/ZIP 0 Other NUMBER 724778 EXPIRATION DATE 08/' GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range _ Section INTENDED USE ❑ Domestic/Private jI�Xlrrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name ------ 7—onTa—ct Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other 1 . ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnicalf borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair �EAy MEAiT 0 New Pum ❑ Pum Replacement um Repair 0 Raise Well CasingWED WELL CONSTRUCTION 25�8� 6 OV Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other ',A~ -� zor Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Siz®LEMV/Ro /N C��Nmeter ❑ Conductor Casing in diameter / Conductor Casing Depth ft s Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other n Rr.tard;;nt / Arralarntnr fnmmal PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other 0 Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP bmersible❑ Turbine ❑ Other HP__15 5 Pump Set 1 26 ft Stan ing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT .I AM IN COMPLIANCE WITH ALL WORKERS COMPE ON LAWS. SIGNED UTII'II► 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 2, TITLE CEO DATE 1 1Z23/201 6 " ��'f •*�* Via...; �� PUMP/WELL is located approx. " -i + •- _. s:.;,,, 362.5 ft from the road. 0 40 off EP RTMENT USE ONLY Application Accepted By C Date /I Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By Date COMMENTS nJ r z 1100 r` , 01 14 .! 0 LA i m D 0 m m N N Area�T Employee ID#��i� SPECIAL Well Permit WAIVER Received Constructed Well Depth ft PE Codes Sc Info 1 . Chec as y - Date Permit/ Service Request # Invoice # Well ID# 25�8� 0.�'' II zq �c, M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 2, TITLE CEO DATE 1 1Z23/201 6 " ��'f •*�* Via...; �� PUMP/WELL is located approx. " -i + •- _. s:.;,,, 362.5 ft from the road. 0 40 off EP RTMENT USE ONLY Application Accepted By C Date /I Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By Date COMMENTS nJ r z 1100 r` , 01 14 .! 0 LA i m D 0 m m N N Area�T Employee ID#��i� SPECIAL Well Permit WAIVER Received Constructed Well Depth ft PE Codes Sc Info Received B Chec as Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 25�8� 0.�'' II zq �c, S�v07 31 W�oo3�lo cnu8 8/04/008 WELL /PUMP PERMIT