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3 <br />20184 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1668 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDREss 4946 E. 8 MILE RD. <br />CITY/ZiP STOCKTON <br />CA 95212 <br />CROSS STREET ---9_9 E , FRONTAC <br />F.. Rapti U YJ G <br />�) PARCEL SIZE -7--'34 LAND USE APPLLTICATION # <br />�� <br />OWNER NAME Fo'i _ , ^– ;�,Q' <br />�3 L �/ ` TG n # <br />ruU <br />w /+ y �� <br />PHONE 48 3 - 4 7 2 6 <br />OWNER ADDRESS s A Itil R / <br />Z Y WN o n y r uy Q <br />io I— CITY/STATE/ZIP <br />lJ �1 fJ l' l� 4 S G Y <br />CONTRACTOR Delta Puma-.qTnC'xmnN <br />ARMATTIRF <br />& MOTOR WORKS <br />ffi Q. 209-466-9625 <br />CONTRACTORADDRESS 646 S. <br />California Street <br />CITY/STATE/ZIP <br />Stockton, CA 95203 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE 0 C-57 X C-61 <br />0 D-09 ❑ Other <br />NUMBER 724778 <br />EXPIRATION DATE 081 p <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Townshin Ranno SnrH— <br />INTENDED USE ❑XYAmestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization~ <br />❑ Public Water System <br />If different from Owner a r ys em ame Contact Name or Phone Number <br />...,R,. a iveW even a Kepiacement wen ❑ Well Alteration/Modification 0 Other <br />O MonitoringWell(s) #ofweffs O SoftBorfn9() ❑Geotechnical <br />s #of borings #of borings <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />0 New Pump ❑ Pump Replacement Pump Repair ❑Raise Well Casing <br />Wat 1 C nucroi,rr, <br />Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _, in Thickness/Gauge/ASTM Sched O Steel D Plastic 0 Stainless Steel 0 Other <br />Grout Seat Depth ft 0 Neat Cement (94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other D 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 ❑ Christy Box ❑ Stove Pipe <br />PUMP bmersible❑ Turbine ❑Other HP 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. t 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 COMPENSATION LAWS. <br />M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO DATE 3 / 2 0 / 2 01 8 <br />- <br />EPARTMENT USE ONLY <br />Application Accepted By Date Z l y <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Insp tion By _ <br />COMMENTS Ci <br />i <br />SC Received <br />s Info g <br />asu /,//A <br />Date <br />✓v 1 C' n ►� <br />Date <br />367S -7 <br />Area 1 I G/ Gl Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Service Request # <br />Well Depth ft <br />QC,e,Ve. new C krCIL <br />Invoice # I Well ID# <br />EHO 43-06 <br />8/04108 <br />WELL tPUMP PERMIT <br />m <br />9 <br />m <br />�F <br />