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19099 WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (ZU9) 953-7b9! FOR INSPECTIONS JOB ADDRESS CROSS STREET OWNER NAME OWNER ADDRE: 3300 W. TR£DWAY RD. DEVRIES RD. APN 055-18-003 LAVIKt5 I YEAR FROM UATE ISSUED CITY/ZIP LOD I 95242 PARCEL SIZE 60 LAND USE APPLICATION # PHONE209 969-5225 LODI 95242 CONTRACTOR Delta Pump _STnCKTnN ARMATURE & MOTOR WORKS E&Q. 209-466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP Stockton, CA 95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS _ LICENSE ❑ C-57 X C-61 CITY/STATE/ZIP ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION 08/ GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑ Domestic/Private Cgkgation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water ys em Name Uontact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other 4 # of borings # of borings ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) ❑ Geotechnical z . ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair I I ❑ New Pump ,Q,Pumo ReDlacement ❑ PumD Reoair ❑ Raise Well Casina rn —4 1 m �*+ Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Cn Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diam er ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-90 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Subme❑ Other _ HP _ Pump Set % (� ft Standing Water Level ft 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUUM �24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS r I SIGNED_..y^ _...... .rte -.�e.�.�t_,e _ TITLE CEO DATE PUMP/WELL is located approx. 319. Ft. from DeVries Rd. See insert DriPARTMENT USE ONLY Application Accepted By Date Grout Inspection By Date Pump Inspection By Date 2 Soil Boring Inspection By Date Areae Employee ID#� SPECIAL Well Permit WAIVER Received Constructed Well Depth ft rn M M D 0 0 m m N PE Codes SC Received Info "hec ash Amount Remitted Date Permit/ AM,2e Request # Invoice # Well ID# o� �ocri3 , `�' IL IW 14)051 q5 8/04/08 V WELL /PUMP PERMIT