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19970 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL (LUU) y53 -!by/ FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5816 S . JACK ;_.TONE RD. CITY, STOCKTON 95215 <br />CROSS STREET CAR I PQS;A APN 1 83-05-006 PARCEL SIZE 84 . 5aND USE APPLICATION # <br />OWNER NAME <br />• 1• �� WN.39 <br />OWNER ADDRESS SAME CITY/STATE/ZiP <br />CONTRACTOR Delta Pump-STncKTnN ARMATURE & MOTOR WORKS IIE0@:._209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE ❑ Domestic/Private �tigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System \\ <br />If different from Owner: Water System Name Contact Nain-To-r one um er <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair - PAY, <br />❑ New Pump ❑ Pump Replacement 305Pumo Repair [IRaise Well Casino FN7. <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other V <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel SizeBoa ,t dla ter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft R42" N'Y <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other �-NNr <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gat water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Mmersible❑ Turbine ❑ Other HP r; 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH T HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATI N LAWS. <br />/ <br />MINIM ZU24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED , �� L/��� TITLE CEO DATE _ 1 1 1 1 Q1 2 () % _ <br />NOTE: <br />PUMP SET & STANDING lv"rrriTER LEVEL <br />IS UNKNOWN UNTIL THE JOB IS DONE <br />WATER TANK SHED <br />PUMP/WELL IS LOCATED JUST <br />NORTH OF THE MILKING ROOM. <br />NEXT TO THE WATER TANK SHED. <br />APPROX. 60 FT. FROM THE ROAD. <br />MILKING ROOM`' <br />iw- <br />Application Accepted By <br />EP RTMENT U E O LY <br />Date <br />Are Employee ID# <br />U <br />Grout Inspection By <br />Pump Inspection By <br />naDate <br />Date <br />SPECIAL Well Permit <br />WAIVER Received <br />Invoice # <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth <br />ft <br />COMMENTS <br />ISWroo3�S�� <br />T <br />1 <br />m <br />D <br />0 <br />0 <br />M <br />M <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />4;2:,h2.qw <br />tash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />ISWroo3�S�� <br />V 9.YY11 WELL /PUMP PERMIT <br />aroa/oa <br />