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1£5535 - CORRECTED 9/27/1 WELL/PUMP PERMIT FAXE® <br />- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - SToc 95?n �' fi�68 34 )A <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />I <br />JOS ADDRESS <br />17550 E. COPPEROPOLIS RD. CITY/ZIP �Tnrxmn-N-Q5215 <br />CROSS STREET <br />OWNER NAME <br />PARCEL SIZE.8 0_1 AMD USE APPLICATION # <br />t+U �•neycr'r�j PHONP209 969 4889 <br />OWNER ADDRESS�jc�i ca 139 <br />Ct1YTSTA'T'&PFARMTNGTON CA M <br />CONTRACTORDelta P= STC)rKT0N WORRSm <br />x.209-466-9625 � o <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton CA 95203 a <br />SUBCONTRACTOR �d A <br />PHONE <br />ISUBCOHTRACTOR ADDRESS C1TY(STATE�Z\P � 1 <br />LICENSE G C-57 X C-61 a D-09 0 Otherr <br />NUMBER 7247%8 EXPIRATION DATE O$�i� <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Township Range Section <br />INTENDED USE 0 Domestic/Private �Jrrigation/Agricultural G Industrial O Water Quality Monitoring 0 Soil Sampling/Characterizafion <br />0 Public Water System <br />It ditforenl from Ovmer: a er ys em ame <br />on a ame or one um er <br />11'PE OF WortK G New Weil 0 Replacement Well C We11 Aiteration/Modification 0 Other <br />0 Monitoring Welf(s) # of wells i✓ Soil Boring(S). # or borings # of borings <br />Out -Of -Service Well -, a Geotechnical <br />Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />C New Pump C Pumn R2nincom 4 n o,,,.. -- <br />Drilling Method C Mud Rotary 0, Air Rotary G Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom <br />P 0 Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />Grout Seal De th 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Depth—fl ft C Neat Cement (94 Ib bag/5-70 gal water) C Sand Cement <br />9eMonite (20% solids) D Other sack mixl7 gal water <br />Grout Placement Method 0 Pumped Free Fall 0 Other <br />D Retardant /Accelerator (name) <br />PEDESTAL installed By C Driller G Pump Contractor 0 Other <br />G Concrete Pedestal Dimensions: Width <br />it Length 9 h Thick <br />__in_ 0 Christy Box 0 Stovepipe <br />PUMP 0 Submersible Turbine G Other — ` HP <br />Pump SetStanding Water Level k ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS Af'PLtCATION 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 MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />-�� TITLE CEO DATE <br />i — <br />.. DEPARTMENT USE ONLY <br />Application Accepted Sy . <br />Date <br />Grout Inspection By --- <br />Date <br />Pump Inspection By <br />Date 2 <br />Soil Boring IFIDection By <br />COMMENTS_ ll vr+ n Date <br />� Info <br />ti3 8 2 i c;S v <br />EHD 43.06 <br />8/04108 <br />Amount --T— <br />i Date <br />-120" 3 <br />U <br />Area (LC, 1=mployee ID#�� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />WP w3- q I <br />Invoice # <br />Well ID# <br />WELL /PUMP PERMIT <br />ft <br />I� <br />m <br />O <br />M <br />