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Zruhu.l S'Gol�1 y ► (q li�� �' f � ...._ <br />19369 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 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 13341 S. ROB .RTS RD CITY/ZIP STOCKTON 95206 <br />CROSS STREET UNM INE RD, APN 1 91 08 008 PARCEL SIZE3 .- 84- LAND USE APPLICATION # <br />OWNER NAME JACK4LARK I N Fr?k n cf2 Tt' PHONE 2 0 9 463 7056 <br />OWNER ADDRESS -3290 W_ rTNn T r\TE RD . CITY/STATE/ZIP STOCKTON CA 95206 <br />CONTRACTOR Delta Primp _.qTnrT<TnN ARMATugF. & MnTnR WORKS ffAfih. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCOt'ITRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C C-57 fit' C-61 0 D-09 0 Other NUMBER 724778 EXPIRATIONDATE 08/I1 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Tnwnshin Rnnnn c « <br />INTENDED USE 0 Rkmestic/Private 0 Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: a er ys em ame Gontact Name or Phone Number <br />T.i..� <br />W ivcw c! u r<episcemen[ vven <br />❑ Well Alteration/Modification <br />❑ Other <br />Permit/ <br />Service Request # Invoice # <br />G Monitoring Well(s) # of wefts <br />C Soil Boring(s) <br /># of borings 0 Geotechnical <br /># or b�� <br />My <br />0 Out -Of -Service Well <br />pOut-Of-Service Well Renewal <br />❑ Cross -Connection Re air <br />p <br />Re CE��FD <br />C New Pump C Pump Replacement <br />❑yl�rimp Repair <br />C Raise Well Casino <br />/ <br />Drilling Method C Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool C1 Push Point ❑ Other SANjo <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size HE4.4N rle�,'jl` fteter <br />C Conductor Casing in diameter / Conductor Casing Depth ft k,4e.N <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft C Neat Cement (94 lb ba9/5-10 gal water) C Sand Cement sack mixl7 gal water <br />C Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br />PUMP u mersible(D Turbine C Other HP Pump Set 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 />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 THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 2� ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO <br />y' DATE 4/4 4/294 7 <br />y <br />mm <br />D <br />0 <br />v <br />A <br />VED <br />D PARTMENT USE ONLY <br />Application Accepted 8 Date Area/ %�/ Employee ID#_ at:fw <br />Grout Inspection By #L0_7__Date iii SPECIAL Well Permit <br />Pump Inspection By Date Q L (7 % WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS <br />PE <br />Codes <br />EHD 43.06 <br />8/04/08 <br />�� <br />Info <br />rceceivea <br />By <br />I Amount <br />Remitted Date <br />Permit/ <br />Service Request # Invoice # <br />Well ID# <br />15-° <br />I <br />6,'' I� I-) <br />vvroo3ltu3 <br />WELL /PUMP PERMIT <br />