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3 <br />20558 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDARLF hFRMIT COI I (9(191 Q53_7RQ7 eno ImeacPTlnAle M%rn#ML-C 4 vim.. ... <br />JOB ADDRESS 6101 E. 8 MILE RD CITY21P_ STn(xT()N 9r,911? <br />CROSS STREET— jR A T T. R [),D 1p pAC K S APN 063-03-014 PARCEL SIZE 5 - 8 9 LAND USE APPLICATION # <br />OWNER NAMEPHONE 403-5988 <br />OWNER ADDRESS CA.Mg CITY/STATE/ZIP <br />CONTRACTOR Delta Pj=_S_T TON ARMATURE R MOTOR WORKS ff"Q- 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITYISTATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 0 C-57 X C-61 0 D-09 a Other NUMBER 724778 EXPIRATION DATE 08/1% <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE (XRomestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑'Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner. a er ys em Name Contact Name or Phone NUMber <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s)rl of bode9 s of bo <br />Q Geotechnical # borings <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair PA <br />❑ New Pum ❑Pum Re lacement um Re air 0 Raise Well CasingY <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Sizei dart <br />0 Conductor Casing in diameter / Conductor Casing Depth ft SAN 7@r <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0OAQU/N <br />Grout Seat Depth ft0 Neat Cement (94 Ib bag/5-10 gal water) 0 Sand Cement ��I k�I7G>�iter <br />0 Bentonite (20% solids) 0 Other TjyE <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 />11L -U _MF R ubmersible 0 Turbine 0 Other HP Pump Set ft Standing Water Level ft <br />I 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSAT <br />MINIMU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO DATE 7-,L1 1T1 8 <br />PUMP WELL is located approx. 142 ft. from, the road. <br />See insert <br />y. <br />y. <br />tea- <br />3 <br />P RTMENT U E ONLY <br />AppticaGon Accepted By�� Date Area Employee ID#� <br />Grout Inspection By Date PECIAL Well Permit <br />Pump Inspection By DateiTp_�Iff WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />awruu WELL /PUMP PERMIT <br />v, <br />mm <br />D <br />0 <br />C7 <br />