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: 17276 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT <br />WELL/PUMP PERMIT <br />1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT (;ALL GUJ) U04-tioUt FOR INSPECTIONS LAVIKtJ "I TEAR FROM DATE ISSUED <br />JOB ADDRESS 5001 UACK TONE RD. G 1 ^ CITY/ZIP STOCKTON 9 5 215 <br />CROSS STREET E. MARIPOSA RD. APN I D ` / ~� �� PARCEL SIZE, LAND USE APPLICATION # <br />OWNER NAME THOMP S N RANCH PHONE 209 639 1583 <br />OWNER ADDRESS SAME CITY/STATE/ZIP <br />CONTRACTOR Delta Pump _.TnrK'T'nN ARMATURE & MOTOR WORKS 11"Ih. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 X C-61 <br />❑ D-09 ❑ Other. <br />CITY/STATE/ZIP <br />NUMBER 724778 EXPIRATION DATE 08/1'i <br />GEOGRAPHICALINFORMArION: Coordinates X Y Township Range__ Section <br />INTENDED USE ❑ Domestic/Private XXrigation/Agricultural 0 Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Num er <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />0 Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />XI2(ew rump u rump mepiacemem u rump repair u raise vveu Lasing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air'Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom O Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP 0 Submersible urbine ❑ Other HP Pump Set ft Stan ing Water Level 77 2 ft <br />I 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 />I;UKKttNT AND ACTIVE VViTH THE CALIFORNIA CONTKACTURS STA'i E LICENSE BOARD AND THA"f .1 AM iN COMPLIANCE VVITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />/ IJ • 10 - (ip <br />SIGNED ,cC-=-+-�'--,;-,,�_....._.�_�•.•�-"`'�."��..r.•�._ TITLE CEO DATE <br />ur <br />mm <br />D <br />O <br />O <br />A <br />m <br />in <br />N <br />TH <br />Application Accepted By <br />DE P .4RTMENT U.'E h)IVI_'� <br />Date <br />Area _ Employee ID# <br />heck <br />sh a <br />Grout Inspection By <br />Date A <br />SPECIAL Well Permit <br />t~, <br />Pump Inspection By <br />Dateo ILI2=311 <br />WAIVER Received <br />ov <br />Soil Boring lnspecti By <br />Date <br />Constructed Well Depth <br />ft <br />COMMENTS d '1 <br />Q L e.fs f • !� 124 /yLLc3 <br />'' �Yt <br />-� 713117 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />heck <br />sh a <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />ov <br />� <br />I3l�, <br />C) <br />'/U I <br />8/04/08 vV WELL /PUMP PERMIT <br />