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20638 WELLIPUMP PERMIT <br />.c)AN JOAQUIN ('^UNT', E:JVIRONMENTAL HEALTFI DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205.6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT e.;,",1p..i, 0`19) 9163.46)9'i IIOi"; EXPIRES 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS 5797 F._ MATN ST CITY/ZIPSTOCKTON 95215 <br />CROSS STREET $T.R D AVE APN 11V -77� V j PARCEL SIZE 1 4 1 9 -AND USE PPLICATION # <br />OWNER NAME GREG BUSALACHIZC�V � {/j� �� a % PH N 09 986-4237 <br />OWNER ADDRESS A pox 50-11 CITY/STATE/ZIP STOCKTON CA 95205 <br />CONTRACTOR Delta Pump STnC'KTQN ARMATURE & MOTOR WORKS 111 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP (� <br />LICENSE 0 C-57 X C-61 C1 D-09 0 Other NUMBER 724778 EXPIRATION DATE�'0 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE ❑ Domestic/Private Ckkgatlon/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner, a er ystem ame on ac ame or one um er <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />0 Monitoring Well(s) # of wells 0 Soil Borin S9O ❑Geotechnical <br /># of borings # of borings <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />0 New Pump❑ �ymp Replacement 11Pump Repair ❑ Raise Well Casln2 <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom C Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel C. Other <br />Grout Seat Depth ft ❑ Neat Cement (94 /b bagi5-7C gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />Installed By ❑ Driller 0 Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length _ ft Thick in C Christy Box ❑ Stove Pipe <br />PUMP Ik)Vbmersible❑ Turbine ❑ Other HP _ Pump Set1.51 ft Standing Water Level <br />1 <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 />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MIMMl1-111i 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED_. -_ :-...� � .... _... <br />_zs-�,.,,_,_ ._.� CEO / / <br />i� TITLE DATE? 31 18 <br />EP TMENT E Nj,Y <br />Application Accepted By Date l oL' <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID#� <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />8A)4t08vV WELL /PUMP PERMIT <br />T <br />-{ <br />mD <br />b <br />0 <br />A <br />M <br />