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20481 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 />_0 <br />JOB ADDRESS 2FRR ujnjV 9---nNTAC. Rn CITY/ZtP_STOCKT_ON 9521 5 m <br />m <br />CROSS STREET CARPENTER RD. APN 1 7 9 -1 5 - 01 9d <br />PARCEL SIZE 0 2 G SAND USE APPLICATION # <br />OWNER NAME FRANCIS GERMANNrn <br />PHONE 4 81 -19 6-11 <br />OWNER ADDRESS 2386 ROBINDALE CITY/STATE/ZIP STOCKTON CA 95205 /1 <br />CONTRACTOR Delta Pump qm(lC'xTnN ADIVIAmUvr & MOTQR WORK ffF� 209-466-9625 <br />CONTRACTOR ADDRESs 646 S. California Street CITYISTATEIZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS CITY1S7ATEiZ1P <br />LICENSE ❑ C-57 X C-61 0 D-09 0 Other NUMBER 724778 <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />PHONE <br />EXPIRATION DATE 08 / ft <br />INTENDED USE <br />Y Township Range Section <br />O R�nestic/Private C Irrigation/Agricultural 0 Industrial O Water Quality Monitoring O Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner. a er ys em Name <br />U-- 75came or 7 173—ne um er _ <br />TYPE OF—WORK C New Well 0 Replacement Well 0 Well Alteration/Modification <br />D Monitoring We/l(s) # of wells O Soif Sonng(s) <br />C Out -Of -Service Well D Out -Of -Service Well Renewal <br />C NewPumo Ji,P,imnP—i—..,..,.., — o.—,-,___ <br />0 Other <br /># of borings # d <br />0 Geotechnical <br />0 Cross -Connection Repair ��� <br />D Raise Well Casing <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool D Push Point 0 Other �AfNJOAQVIN Co <br />Proposed Well Depth ft Excavation in diameter D Open Bottom 0 Gravel Pack/Gravel Size LTH T <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />0 Steel 0 Plastic ❑Stainless Steel ❑Other <br />Grout Seat Depth ft O Neat Cement (94 ib bag/5-10 gal water) 0 Sand Cement <br />0 Bentonite (20% solids) 0 Other sack mix/7 gal water <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br />O Retardant /Accelerator (name) <br />PEDESTAL Installe�ByC) �DdllerOPump Contractor ❑ Other <br />G Concensions: Width ft Length ft Thick <br />in ❑Christy Box 0 Stove Pioe <br />rumt, 0 RubmersibleO Turbine 0 Other <br />HP 1 _ 5 Pump Seth_ ft Standing Water Level� � h <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />31GNED <br />TITLE CEO DATE6 / 28/ 18 <br />TMENT USE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />vT <br />Employee ID#4y1ZV <br />SPECT We(I Permit <br />WAIVER Rd <br />Soil Boring Inspection By Date ecerve <br />COMMENTS _ Constructed Well Depth ft <br />Codes I Info <br />END 43-06 <br />8/04108 <br />Amount I Date Permit/ <br />Cash Remitted Service Re uest # <br />3 075— 116-1 � �1, oU ��yTLl <br />invoice # j Well ID# <br />WELL /PUMP PERMIT <br />