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20635 WELL/PUMP PERMIT <br />I, <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 ISS" <br />EC <br />JOB ADDRESS 6060 S JACKTON'-RD CITY/zip STOCKTON 95215 <br />CROSSSTREET MARIPOSA RD. APN 183-06-012 159.2.19 <br />PARCEL SIZE AND USE APPLICATION # <br />OWNER NAME D901 LEINFELDER Fury' j t' 209 979-3834 <br />OWNERADDRESS 6.067 S. JACKT, TONE RD*.'PHONE <br />CITY/STATE/ZIP. STKN CA 9521 <br />CONTRACTOR Delta Pump-STnrxTON ARMATURE & MOTOR WORKS PHONE 209-466-96 <br />25 <br />CONTRACTORADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />PHONE <br />3U5CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />-ICENSE ❑ C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />EXPIRATION DATE 08/0 <br />Y Township _ Ranae SAcHnn <br />-- - LyiXigatlon/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: a er ys em Name <br />­RdQt iName or Prone NUMber <br />I YI-t yr WORK 0 New Well 0 Replacement Well o Well Alteration/Modification <br />0 Other <br />0 Monitoring Wali(s) # of wells O Soii Boring(s) # of borings ❑Geotechnical # of borings <br />❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal <br />❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement 9fump Repair <br />WELL CONSTRUCTION <br />❑Raise Well Casin <br />Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool 0 Push Point <br />0 Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in <br />diameter / Conductor Casing Depth <br />ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad 0 Steel <br />Grout Seal Depth <br />0 Plastic ❑Stainless Steel ❑Other <br />ft 0 Neat Cement (94 lb bag/5-10 ga/ water) <br />❑ Sand Cement <br />0 Bentonite (20% solids) 0 Other <br />sack mlxl7 gal water <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Anr`RIPmt r 1--\ <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other <br />0 Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in 0 Christy Box D Stove Pi <br />ruraP ❑ SubmersibleCkT, lrbine ❑ Other HP 7 S Pump Set ft Standing Water Level A-2 Q ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THJOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />WORKERS COMPENSATION LAWS. AT .I AM IN COMPLIANCE WITH ALL <br />MINIMUM 24 HOUR ADVANCE NOTICE REOUIRFn FnR tnlcorrTlr,��� <br />Application Accepted Sy Date V 7 00 <br />� <br />Grout Inspection By Date <br />Area SPECIAL Well Permit <br />Employee ID# <br />Pump Inspection By Date .� Z <br />WAIVER Received <br />Soil Boring inspection By <br />Date <br />COMMENTS Constructed Well Depth ft <br />E I <br />PSC <br />Codes Info <br />Received <br />B <br />hec <br />Amount <br />Date <br />PermiU <br />8 �° <br />� <br />ash <br />emitted <br />I �/ ix <br />Service Re uest # Invoice # Well ID# <br />(A)r ut� = � <br />EHD 43-06 <br />8/04/08 <br />WELL /PUMP PERMIT <br />m <br />m <br />D <br />v <br />M <br />N <br />fA <br />