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ox RECEIVED <br />2 C-3 70 WELL/PUMP PERMIT # MAY 17 2018 <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 1 YEAt2j��A! T p <br />JOB ADDRESS 1 044 E. MAnRrif;A Rn CITY(ZIP LATHRQPY CA 9slin m <br />D <br />Q <br />'CROSS STREET GUTHM11- i,LER RQ APN241 —41 — n n PARCEL SIZE 7 . 9 7 LAND USE APPLICATION # <br />OWNER NAME -7 <br />U) <br />-T—ONV NTOQET-1 1 /1`12 J LL}G PHONE 209 4R? -6969 <br />OWNER ADDRESS P.O. BQX 3 4 0 /jI f"l �i/1[%f/'��rfiSrY�/ �� �n�/STATEIZIP ZFR N T(' q <br />CONTRACTOR - Delta Pump-,qTCI('KTr)N AgMATljgF R MQTQR WORKS (146t 209-466-9625 <br />CONTRACTORADDREsS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br />LICENSE 0 C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/� <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE ❑�mestic/Private C Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/C roti , <br />C Public Water Stevmecm /+� ���C/� <br />If different from OWater ystem Name -- 77�7,77`n--pF-����` <br />TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />G Monitoring Well(s) # of wells C soi( Sorin s # of borings f <br />9l) ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair J <br />C New Pum m Replacement ❑ Pum Repair 0 Raise Well CasingHNM Co <br />WELL CONSTRUCTION ENVIRO <br />� <br />Drilling Method ❑Mud Rotary D Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other RTMENT <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom D Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter f Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel 0 Other <br />Grout Seat Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement <br />sack mixR gal water <br />❑ Bentonite (20% solids) D Other <br />Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal Dimensions: Width (t <br />PUMP submersible❑ Turbine ❑Other Length ft Thick in D Christy Box 0 Stove Pipe <br />HP _1_ Pump Set ft Standing Water Level It <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 AC E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS <br />M1 UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO <br />DATE 5/14/18 <br />PUMP/WELL <br />is approx. 167 ft. -' 1 <br />from Guthmiller Rd. inside ; <br />small shed. <br />I 13 <br />=- <br />kJ,r� <br />w ,.- <br />D A TM E NT US E O N L Y <br />Application Accepted By 0ate Z <br />Grout Inspection By Date <br />Pump Inspection By y Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />AreaEmployee ID#Z+lf G// <br />SPECIAL ell Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />WELL /PUMP PERMIT <br />