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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES T YEAR FROM DATE ISSUED <br />I41 <br />Jos ADDRESSg _ WAT.KR T.ANF clTYrzIP _STmCKTON A 95215 � <br />Q F. <br />CROSS STREET_ SFrTTON APN 173-28-016 PARCELslze9.53 LANDUSEAPPLICATION# X <br />m <br />OWNER NAME ANGELO CUNEO PHONE 670-5-97 N <br />OWNER ADDRESS SAMP. CITYISTATEIZIP <br />CONTRACTOR Delta PS x._209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street: CITYiSTATFJZIPStockton, CA 95203 <br />SUBCONTRACTOR __ PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE G C-57 N C-61 <br />GEOGRAPHICAL INFORMATION: <br />D D-09 D Other NUMBER <br />Coordinates X Y <br />CmyISTATE1z1P <br />EXPIRATIONDATE o$/ <br />Township Range Section <br />INTENDED USE D Domestic/Private XXrigation/Agricultural G Industrial D Water Quality Monitoring C Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Ovrner. Water Sysrem ame on a ame or PhOnO Number <br />I YPE OF WORK G Now Well 0 Replacement Well 0 Well AlteratioNModification <br />C Monitoring Well(s) # of wells D Soil Boring(s) <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal <br />C New PumpC Pump Replacement$tlm0 Repair <br />0 Other <br /># of borings <br />u Geotechnical <br />0 Cross -Connection Repair <br />D Raise Well Casin <br /># of borings <br />vvELL CONSTRUCTION <br />Drilling Method C Mud Rotary Air Rotary 0 Auger D Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft 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 D Steel 0 Plastic 0 Stainless Steel D Other <br />Grout Seal Depth ft 0 Neat Cement (94 ib bag/5-10 gal water) C Sand Cement <br />sack mix17 gal water <br />;. i3entoritte (20°lo solids) O Other <br />Grout Placement Method 0 Pumped Free Fail 0 Other <br />D Retardant /Accelerator (name) <br />Dc <br />nscanea By u unuer 0 Pump Contractor 0 Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in_ u Christy Box 0 Stove Pipe _ <br />PUMP 0 Submersible CXRrbine G Other HP 20 Pum Set T <br />P ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 13E 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 COMPENSATIO S. <br />MINIMUM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO <br />DATE7/31 12017 <br />I 1 <br />I � } <br />PUMP/WELL Is located p` <br />approx.. 127.72 ft. from <br />the road. <br />NOTE: <br />PUMP SET & STANDING WATER LEVEL <br />IS UNKNOWN UNTIL THE JOB IS DONF <br />Q„E AR' MENT USE ONLY <br />Application It <br />Accepted Sy Date <br />Grout Inspection By Date <br />Pump Inspection By ; <br />Date <br />Soil Boring Inspection By <br />COMMENTS Date <br />SC Received Check#/ <br />Info <br />Amount <br />a Cash <br />Remitted <br />EHD 43.06 <br />8/04/08 <br />M <br />HEALTti I, �NTqL . <br />AToa� Employee ID#l�T <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br /># I Invoice # f Well ID# <br />WELL /PUMP PERMIT <br />