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M <br />' �n17ti <br />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 />c-, cn <br />JOB ADDRESS �-O��KRS�� CITY/ZIP - STOCKTON 95215 D <br />O <br />CRo55 STREET_ CARPENTER RD APN1.7 <br />D-0_7 PARCEL SIZEn�7 LAND USE APPLICATION # <br />m <br />OWNER NAME THOMAS LAFAVER J6a �(a }� PHONE 2 0 9 670 5429 <br />OWNER ADDRESS SAMP, CITY/STATEIZIP <br />CONTRACTOR Delta Pump—STOCKTON ARMATURE R MOTOR WORKS M16Q. 209-466-962 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />PHONE <br />[LI SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />ICENSE D C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/a <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Townshin Rannn ce..s�.... <br />v <br />INTENDED USE RRomestic/Private E Irrigation/Agricultural a Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />C Public Water System <br />If different from Ovmer: a er ys em amo on ac ame or one um er <br />VV VKn a rvew vven a Keplacement Well ❑ Well Alteration/Modification ❑ Other <br />0 Monitoring Well(s) #or weiis Q Soii Sorin s #ofborinps of bo"s <br />9l) ❑Geotechnical <br />❑ Out -Of -Service Well O Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />D New Pump 5 Pump Replacement .;,Pump Repair ❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary G Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom C Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel D Plastic ❑ Stainless Steel D Other <br />Grout Seal Depth ft C Neat Cement (94 Ib bag/5-10 gal water) G Sand Cement— sack mix/7 gal water <br />C Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall 2 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersibleo Turbine O Other HP Pump Set ft Standing Water Level ft <br />1 HEREBY CERTIFY THAT 1 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�LAWS. <br />IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATI4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED DATE <br />L, TITLE CEO 2/27/2018 <br />PUMP/WELL is located approx. 13 ft. <br />from the south side of the house <br />NOTE: THIS WAS AN EMERGENCY ISSUE OF NO WATER <br />TO THE HOME. WE HAD TO PULL THE PUMP PRIOR TO YOU <br />RECEIVING THIS APPLICATION. <br />Le iico G�rrt <br />Office Manager <br />u <br />- <br />PAYMEN <br />RECEIVE <br />MAR 0 5 7010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL` F, <br />HEALTH DEPARTMENT <br />j!tlU P A T M E N�TUWEN <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />i <br />AreaEmployee ID#yv <br />SPE IAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Sc <br />1 Received <br />CCheck#1 <br />Amount <br />rm <br />Permit/ <br />rm / <br />Codes <br />Info <br />B <br />ash <br />emitted <br />Date <br />Service # <br />Invoice # <br />Well ID# <br />EHD 4306 <br />8/04108 WELL /PUMP PERMIT <br />