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20033 S <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADoREss 4523 S. INLAND DR. CITY/ZIP S TOCKTON 95206 <br />CROSS STREET HWY 4 APN 131-27-002 PARCEL SIZE 0 _ A 3 LAND USE APPLICATION # <br />OWNERNAME RQRP.RT T140MAq PHONE 209 610-2823 <br />OWNER ADDRESS SAME CITY/STATE/ZIP <br />CONTRACTOR Delta Pump_STpCxTnN ARMATURE & MOTOR WORKS ffAfitt. 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 �Q <br />LICENSE ❑ C-57 X C-61 0 D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/f p <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br />INTENDED USE Damestic/Private 0 Irrigation/Agricultural C Industrial 0 Water Quality Monitoring ❑'Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner, a er ys em Name n acName or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /># of borings # of boringsP <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) ❑ Geotechnical AyjlOZA <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair RECEIVE <br />0 New Pump ❑ Pump Replacement §tRump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point47 26 <br />0 Other" coq <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size N� iki ia4Siete <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 Ib bag/5-10 gal water) 0 Sand Cement sack mixl7 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br />PUMP }¢Submersible❑ Turbine ❑ Other HP ___J__5_ 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 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 TITLE CEO <br />DATE 1211812017 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspec i. By <br />COMMENTS , <br />'�• � • - -J rem • <br />mm <br />D <br />0 <br />a <br />m <br />m <br />Area Employee ID#'" <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />hec <br />as <br />Amount <br />Remitted <br />Date <br />Permit! <br />Service Re uest # <br />Invoice # <br />Well ID# <br />5D <br />� <br />�3dagb <br />u; P <br />yV <br />8/04/08WELL /PUMP PERMIT <br />