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19619 <br />lk WELL/PUMP PERMIT <br />SAIL 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 ISSUE^ <br />�JoB ADDRESS —1051 SPERRY RD. CIrY21P sTnf'KTnN A 5? QIa <br />CROSSSTREET ARCH &AIRPORT W N _1 77-28-039 PARCEL SIZE -12-9 —94kD USE APPLICA71ON # <br />OWNER NAME PHONE 982-1500 <br />OWNER ADDRESSC n nag j�1 '� (� �I 1 L� n t � I(J -;y7 <br />Jl i CITY/STATE/Zip �4�F_ �t/l��/� t—�� <br />CONTRACTOR Delta Ptunp_CTOCKTON ARMATURE MOTnR WORYSS—ffAiQ, `9-466-9625 <br />CONTRACTORADDRESS 646 S. California Street CITY/S7ATFJZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />"'-" PHONE <br />I <br />SuBcosTRACTTATE <br />OR ADDRESS CITYISIZIP <br />t <br />LICENSE O C-57 ' 0-61 U D-09 D Other NUMBER 724778 ExPIRATIONDATE_ 08/17 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Township Range Section <br />INTENDED USE 0 Domestic/Private',�rrigation/Agricultural G Industrial C Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑Public Water System <br />If different from Owner: a er ys em ame <br />_ on a ame or tnOne NUmber <br />TYPE OF WORK 0 New Well 0 Replacement Weil G Well Alteration/Modification <br />Monitoring Welf(s) # of wefts L; Soil Boring(s). <br />Out -Of -Service Well 0 Out -Of -Service Well Renewal <br />0 Other <br />At of borings <br />u Geotechnical <br />0 Cross -Connection Repair <br /># of borings <br />Drilling Method C Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth It Excavation— <br />in diameter 0 Open Bottom D Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />0 Steel D Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 Ib bag/5-?0 gal water) C; Sand Cement <br />8entoritte (20% solids) p Other sack mixl7 gal water <br />Grout Placement Method 0 Pumped Free Fall 0 Other <br />0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Drfiler 0 Pump Contractor D Other <br />Concrete Pedestal Dimensions: Width ft Length 9 ft Thick in u Christy Box G Stove Pipe <br />PUMP 0 ftmersibleO Turbine 0 Other <br />HP n Pump Set ft Standing Water Level 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND IVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS <br />MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />;1GNED <br />TITLE CEO DATE 7/14/2017 <br />s ' <br />L--- NOTE: <br />PUMP SET & STANDING WATER LEVEL <br />IS UNKNOWN UNTIL THE JOB IS DONE <br />ApPtitxtion Accepted Sy <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Recelveci Check#/ <br />'s info fay Cash <br />EHD 43.06 <br />8/04/08 <br />"r ENS AOUIN CCU,y v <br />.r IRONMcwf ,n. <br />lump/well is located approx. <br />104.04 ft. from Bridge. <br />__ .. . -. v V 1Y L T <br />Date <br />Date_ <br />Date t FJ IJ A 1 I S, <br />Aroa� Employee ID# <br />T SPECIAL Well Permit <br />WAIVER Received <br />Date . Constructed Well Depth <br />ft <br />,d Date <br />°� 'F/act <br /># I Invoice # I Well ID# <br />WELL /PUMP PERMIT <br />7' <br />M <br />A <br />0 <br />U <br />M <br />m <br />N <br />