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20486 WELLTUMP PERMIT <br />SAN JOGQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 9868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 4143 N. HUBBARD AVE <br />CITY/z!P STOCKTON 95215 <br />iCR055 STREET CHEROKEE RD APN 087-070-340 PARCEL SIZE O . 7 41 -AND USE APPLICATION # <br />OWNER NAME PHONE 51 LL21C)-?j qQ <br />OWNER ADDRESS 413.1 N. H 1RBARD RD ,Lzj0 l RA*- r '1C ITY/STATE/ZiPSTQCKTON CA 9521 5 <br />CONTRACTOR Delta Pump STnr,KT()N ARMATURE MOTOR WORKS SIA, 209-466-9625 _ <br />CONTRACTORADDRESS 646 S. California Street CITYISTATEIZIP Stockton, CA 95203 - <br />SUBCONTRACTOR ADDRESS <br />LICENSE O C-57 X C-61 0 D-09 0 Other <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />NUMBER <br />CITYISTATEIZIP <br />PHONE <br />EXPIRATION DATE ()8/m <br />Y Township Range Section <br />INTENDED USE CQ�omesticlPrivate 0 Irrigation/Agricultural D Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />C Public Water System <br />If different from CNmer:a er ys em ame <br />_ �Rucl Name or Prone Number <br />TYPE OF WORK C New Weil 0 Replacement Well 0 Well Alteration/Modification <br />C? Monitoring Well(s) # or wefts O Soft Boring(s) <br />C Out -Of -Service Well ❑ Out -Of -Service Well Renewal <br />C New Pump RLAiimn P -1—n 4 ;-, o..—_ <br />0 Other <br /># of bonngs <br />❑ Geotechnical <br />❑ Cross -Connection Repair <br />C Raise Well Casino <br />L!J <br />Drilling Method G Mud Rotary C Air Rotary C Auger D Cable Tool 0 Push Point 0 Other <br />Z018 <br />Proposed Well Depth_ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel S ,VI/ROA14 <br />D Conductor Casing in diameter / Conductor Casing Depth ft„�� <br />Well Casing Diameter _ in Thickness/Gauge/ASTM SchedD Steel D Plastic ❑Stainless Steel D Other EPgRTf14ENT <br />Grout Seat Depth ft 0 Neat Cement (94 lb bag/5-10 gal water <br />C Sand Cement sack mixl7 gal water <br />❑ Bentonite (20% solids) D Other <br />Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other <br />0 Retardant/ Accelerator (name) <br />PEDESTAL Installed By Pe0 Driller 0 Pump Contractor 0 Other <br />C Concrete destal Dimensions: Width ft Length ft Thick <br />in D Christy 80 ❑Stove Pipe <br />PUMP bmersible0 Turbine O Other <br />HP 1 Pump Setft Standing ft <br />PARED THIS APPLICATIONWater Level <br />I HEREBY CERTIFY THAT I HAVE PRE 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS, <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED <br />I+ TITLE CEO <br />DATE <br />F771--- <br />64 7 O ,L1 � <br />PUMP/WELL is located approx. <br />74.67 ft from the road. Under u <br />the trees. <br />FIyt »` <br />EV0 " �E1R#V1. CHvtr; <br />NOTE: THIS WAS AN EMERGENCY ISSUE OF NO WAITER <br />TO THE HOME. WE HAD TO PULL THE PUMP PRIOR TO YOU <br />RECEIVING THIS APPLICATION. WILL NOT HAVE THE PUMP <br />AND WATER LEVELS UNTIL THE JOB IS DONE. <br />Louise Fornos <br />d - <br />Office Manaaar_ <br />I <br />E F TE—E-± <br />EP RTMENT USE ONLY <br />Application Accepted By % Date <br />Grout Inspection By AreaEmployee ID# <br />Rump Inspection By � <br />Date SPECIAL Well Permit <br />Soil Boring Inspection By Date WAIVER Received <br />COMMENTS Date Constructed Well Depth <br />ft <br />WELL /PUMP PERMIT <br />mm <br />g <br />m <br />hd <br />