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19670 WELL/PUMP PERMIT <br />SAN JO�QUIN 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 ISSUED <br />JOBADDRESS499 W- RRTrC,S?R CITY21p T.ATHRnp 45330 <br />CROSS STREET M A NTH E Y R n APN. J 93-14-0-29 PARCEL SIZE1 - 0 1 LAND USE APPLfCATfON # <br />OWNER NAME fn1TT.T.T2lMCMT�i3 M PHONE209 479 4084 <br />OWNER ADDRESS 4 A ME CITYISTATE/ZIP <br />CONTRACTOR Delta Pump.qTAC_KT_()N ARMTTLIRE A MOTOR WORKS x-_209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITYISTATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR _ <br />--- PHONE <br />SUBCOtATRACTOR ADDRESS CITYISTATEJZiP <br />LICENSE G C-57 X C-61 O D-09 0 Other <br />GEOGRAPHICAL INFORMATION: Coordinates X y <br />NUMBER 724778 EXPIRATIONDATE 08/ <br />Township Range Section <br />IN I enutu USE XXorrestic/Private 0 Irrigation/Agricultural G Industrial C Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: a or aystarn Name <br />­111adl Name or Phone NUMber <br />TYPE OF WORK 0 New Well 0 Replacement Weil 0 Well Alteration/Modification D Other <br />0 Monitoring Well(s) # of WelIS L Soil Boring(s) # of borings a Geotechnical # of borings <br />Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />Alm 1 C New Pump X)eump Replacement ❑ Pump Repair 0 Raise Well Casinn <br />Drilling Method C Mud Rotary 0 Air Rotary 0 Auger D Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth it Excavation in diameter 0 Open Bottom 0 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 0 Plastic ❑Stainless Steel G Other <br />Grout Seal Depth ft ^ Neat Cement (94 Ib bag/5-10 gal water) C Sand Cement <br />Bentonite (20% solids) 3 Other sack mixl7 gal water i <br />Grout Placement Method 0 Pumped C Free Fail 0 Other <br />❑ Retardant /Accelerator (name) <br />PFncarAi i_,-.___.. <br />Concrete Pedestal Dimensions: p Width ft <br />❑ Other <br />ft Length It Thick In 0 Christy Box 0 Stove Pipe <br />PUMP tubmersible❑ Turbine D Other Hp <br />—1— Pump Set ft Standing Water Leval 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. 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 />MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED <br />TITLE CEO DATE7/ 1 9/ 2 ()1 7 <br />( i <br />NOTE: <br />PUMP SET & STANDING WATER LEVEL <br />IS UNKNOWN UNTIL THE JOB IS DONE <br />tt LEPTMENT SE NLApplication Accepted By Date <br />Grout Inspection By <br />Date <br />Pump Inspection By J <br />Date <br />Soil Boring Inspection By <br />COMMENTS Date <br />Amount <br />Date <br />EHD 43.06 <br />8/04!08 <br />9 <br />IT) <br />D <br />0 <br />0 <br />m <br />N <br />to <br />Area _// `7 �/ Employee <br />SPECIAL—Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Invoice # <br />W ELL /PUMP PERMIT <br />