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19907 WELL/PUMP PERMIT PJ <br />SAN JO,.t.1UIN 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 V:VDlGCa d Vr. <br />JOB ADDRESS 1 2 7 511 THRRNTON R �� <br />CITY/ZIP LOBI 95242 <br />CROSS STREET_ _ T — R Apt4 055-13-016 <br />PARCEL SIZE 1-6.0—LAND USE APPLICATION # <br />OwNenNAME QTY OF LODT <br />PHONE 209_625-6933 <br />OWNER ADDRESS 2,� 1 w - NL $T <br />CITY/STATE1ZiP LOM CA 9 5 2 4 0 <br />CONTRACTOR p A �rt'(1f'KTO <br />—D�lta Y ARMAT TRF <br />MOTnR t\7n>7xC209_46=2625 <br />CONTRACTOR ADDRESS 646 S. California street <br />— <br />CITY/STATC/ZlP Stockkton, CA 95203 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/7jP <br />LICENSE 0 C-67 I C-61 00-09 0 Other <br />NUMBER 72477$ EXPIRATION DATE l,U J_➢- <br />GEOaRAP1.IICAL INFORMATiON: Coordinates X Y <br />_�. <br />INTENDED USE ❑ Domestic/Private 0 Irrigation/Agricultural (Xkidustriai <br />Town hip <br />❑ Water Quality monitoring 0 Soll Sampl <br />U Public Water System <br />g/Aharacterintiontton <br />If different from Owner: a r ys em me <br />ac me or na um r <br />TrPs.__ ,. 0..., F WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification ❑ Other <br />0 Monitoring Wells) # of wells 0 Soll Bor/ng(S) # or borinpa # of bor1ieDPgyME <br />u <br />❑ Out <br />-Of -Service Well <br />❑New Pum ❑ Pum Replacement <br />Renewal ❑ Cross -Connection Repair RE CEM <br />Il♦/FI 1 rrtnle'Pn,.n•......i um Re air11 <br />RAI4fa \Nall ('I n..i...,. <br />Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger 0 Cable Tool 0 Push Point 0 Other s, 4 I 1 2 <br />Proposed Well Depth ft Excavation In diameter ❑ Open Bottom O Gravel PacWGravel Size in dlametep <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad ___ <br />Grout Seal Depth g O Steel O Plastic O Stainless Steel 0 Other____ <br />0 Neat Cement (94 /b bag15-fogal water) ❑ Sand Cement <br />f 0 Bentonite (20% solids) 0 Other sack mixt? gal water <br />Grout Placement Mathad ❑ Pumped O Free Fall 0 Other <br />0 Retardant / Accelerator (nems) <br />ZV_L5TA.6 installed By 0Griper 0 Pump Contractor 0 Other <br />a Concrete PedsataJ Dimensions: Width ft Length ftThick <br />in 0 C�hrlstyox 0 Stove Pi e <br />P MP ❑ erstble0 Turbine ❑ Other <br />HP Pump Set ft p@ it <br />Standing Water Level <br />(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 />MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />81QNEp 0 TITLE CFO <br />DATE -1_0 <br />PUMP/WELL is located across <br />from .the 4 holding tanks. <br />EPARTMENT /USE ONLY <br />Application Acx8pted By Date 7 ,/ Area L �l� <br />Grout Inspection By Oats Employee ID# _" <br />SPECIAL Well Permit <br />Pump inspection fay + <br />Oats WAIVER Received <br />Soil Boring Inspection By iag <br />COMMENTS, Dob Constructed Well Depth <br />ft <br />03 <br />ND 43.06 <br />04106 <br />®` �I 13M <br />Date <br />invoice # I Well ID# <br />WELL IPUMP PERMIT <br />