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19390 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 13436 N TunR NTO N RD CITY/ZIP LOD I CA 95242 <br />CROSS STREET_ A T,CLr T 5 IST PtnT INTI APN 0 5 5 —13 -- 0 01 PARCEL SIZE ­7-6­44ND USE APPLICATION #r` <br />OWNER NAME _ /�i1 6NA —T(' NE 2O9 969-5225 <br />OWNER ADDRESS SMF I rCITY/STATFJZIP <br />CONTRACTOR Delta Pump—.qTnCKTnN ARMATTTRF R MOTOR WORKS MQ. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />Si3BCOriTRACTOR ADDRESS CITY/STATE/ZIP r <br />LICENSE C C-57 N C-61 0 D-09 0 Other NUMBER %24778 EXPIRATION DATE 08/tj <br />GEOGRAPHICAL INFORMATION; Coordinates X Y Tnwn hin ate--- <br />...._...� ......y„ ..+va.uvn <br />INTENDED USE ADomestic/Private 0 Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: a er ys em ame Contact Name or Phone Number <br />U 1•IGw vvvi! u meplacement vveii <br />❑ Well Alteration/Modification <br />0 Other <br />C Monitoring Well(s) # ofwells <br />❑ Soil Boring(s) <br /># of borings G Geotechnical <br /># of borjngPAYIwEN <br />0 Out -Of -Service Well <br />0 Out -Of -Service Well Renewal <br />0 Cross -Connection Repair <br />RECEIVE <br />❑ New Pump ❑ Pump Replacement <br />I?Tump Repair <br />0 Raise Well Casino <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other sAv JOA i ' ` <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size HE-urndiameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel ❑ Other <br />Grout Seal Depth ft 0 Neat Cement (94 Ib bag/5-10 gal wafer) 0 Sand Cement sack mixl7 gal water <br />D Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP nSubmersibleD Turbine ❑ Other HP _0__5__ Pump Set_ t f ft Standing Water Level 15- ft <br />1 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 />SIGNED <br />H7OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />la<� TITLE CEO DATE4. ' V 6 / —7. <br />DEPARTMENT USE ONLY <br />Application Accepted By _ Date / <br />Grout Inspection By Date _ <br />Pump Inspection By Date <br />Soil Bonn Inspection By Date , <br />COMMENTS JQ17 , fes.. iraiJfns! 1'-11.4 �./".1L, �_ t <br />Codes I Info <br />Amount <br />Remitted Date <br />7n 00 <br />s <br />Area Employee ID# 1�3�—ro <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Pi— <br />Invoice # I Well ID# <br />w�oo31s�s� <br />EHD 43.06 <br />8104/08 WELL /PUMP PERMIT <br />T1; <br />1 <br />m <br />D <br />0 <br />0 <br />m <br />VD, ! JI - <br />007 <br />bcrn <br />TIENT <br />fvEO <br />X017 <br />