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,IV <br />j <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 -7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Jos ADDRESS 10214 E. Waterloo Rd. CITY/ZIP stockton 95215 m <br />CROSS STREET BAKER / PE Z Z I APNO 8 9 - 0 5 0 - 0 2 4 PARCEL SIZE 1 -0 LAND USE APPLICATION # <br />OWNER NAME —SCAN T T—s>:-+•2*B- - V-N,'"Al ( LCAl'Liha ,Jr,1 ;;1 <br />A4 PHONE 209 607-1535 N <br />OWNER ADDRESS Sa7- �` <br />���-�--41ZZ� I�• � CITY/SSTATE/ZIP <br />CONTRACTOR Delta Pumo - STOCKTON ARMATURE & MOTOR WORKSPHONE209-466-962 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP--Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C-57 X C-61 ❑ 0-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1,1 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Tn.... kl- <br />NTENDED USE X Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: a er ys em ame on acName or Phone Number <br />rvnc r%e mt- n n,_... <br />- - - - --- u i—p aconront vveo u vven Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings ❑ Geotechnical <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />-.,a,,,, <br />WELL CONSTRUCTION <br />W I <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diarneter i <br />❑ Conductor Casing In diameter / Conductor Casing Depth ft <br />WeH Casing Diameter _ In Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic ❑ Stainless Steel ❑ Other j <br />Grout Seat Depth ft 0 Neat Cement (94 Ib ba9/5.10 gal water) ❑ Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped 0 Free Fall ❑ Other <br />0 Retardant /Accelerator (name) <br />Ir=.=Q HL msiauea my u unser O Pump Contractor 0 Other <br />0 Concrete Pedestal Dimensions: Width ft Length ft Thick In 0 Christy Box 0 Stove Pipe <br />PUMPR Submerslble0 Turbine 0 Other HP __I_ Pump Set ft Standing Water Level k <br />1 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 .1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS, <br />MINIM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO <br />O <br />DATE <br />NOTE: OOL <br />PUMP SET & STANDING WATER LEVEL <br />IS UNKNONA'N UNTIL THE JOB IS DONE <br />SINGLE FAMILY RESIDENCE <br />PUM/WELL is located approx. 20 ft. from the back <br />of the house. <br />EP RTMENT SE NLY <br />Applicaizon Accepted 8y V <br />Date <br />Grout Inspection By Date <br />Pump Inspection By ru <br />Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />-rw ,0 <br />8M4/08 <br />Employee ID0 <br />SPECIAL _W` Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Date Permit/ <br />Service Request # <br />Invoice # Weft ID# <br />C - <br />WELL /PUMP PERMIT <br />