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20503 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205.6232 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 12R9R1 PPPAurD„ O.1 �1 CITY/ZIP T.(lrl T t -A 25240 CR" STREET�]., AFa6 5 - 0 2 -Q16 PARCEL SIZE 8 . 0 LAND USE APPLICATION # OWNER NAME JOHNN_ G_ j_ E� a-(1 PHONE 3 9 0-1607 OWNERADDRESS SAME I Z`>� (o f� f'' ' � �it�!" [ � CI7YISTATE2IP � C ((t Co 7 � � � 0 CONTRACTOR Delta PUIllp CTOCKTON ARMATURE & Mf)TC1R WQRr(Z > 209-466-962 CONTRACTOR ADDRESS 646 S. California Street CITYISTATEMP Stockton, CA 95203 SUBCONTRACTOR SUBCONTRACTOR ADDRESS CITYISTATEJZIP PHONE (LICENSE 0 C-57 X C-61 0 D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/ft GEOGRAPHICAL INFORMATION. Coordinates X Y Township Range Section INTENDED USE 0 Domestic/Private C}{I�igation/Agricultural 0 Industrial 0 Water Quality Monitoring O Soil Sampling/Characterization C Public Water System If different from Owner a er ys em Name ac ame or one um er ME_ OF—WORK C New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other C7 Monitoring Well(s) # of welts Q sort Boring(s) # or borings ❑ Out -Of -Service Well ❑ Geotechnical ❑Dut-Of-Service Well Renewal ❑ Cross -Connection Repair 0 New Pump 0 Pump Replacement —91 Purrto Rannir P41 Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool ❑ Push Point ❑ Other Jt�'/� � J Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Paok/Gravel Size "n 0 Conductor Casing in diameter / Conductor Casing Depth ft "AtT/-I O� N�T Well Casing Diameter _ in ThicknesslGauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other DEbARTM Grout Seat Depth ft ❑ Neat Cement (94 Ib bag/ 10 gal water) ❑Sand Cement 0 Bentonite (20% solids) 0 Other sack mixR gal water Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/ Accelerator (name) PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other C Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe PUMP bmersible❑ Turbine 0 Other HP Pump Set ft Standing Water Levet ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARDAND THAT WORKERS COMPENS I .I AM 1N COMPLIANCE WITH ALL T MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED y. TITLE CEO DATE 6/2 7Z201i Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS Codes I Info EMD 43-06 a/D4108 Received DE PAI?eTMENT U E O LY Date Date Date Date Date bO'p Area Employee ID#�(J^�(q SPEC AL Well Permit WAIVER Received Constructed Well Depth Invoice # ft Well ID# WELL /PUMP PERMIT IM g X M a