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5 20599 WELL/PUMP PERMIT P ✓' 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_I YEAR FROM DATE ISSUED y JOB ADDRESS 1 (1�A1 F C`nMSTncK RD CITY/Z►P STOCKTON 95215 m Q CROSS STREET HWY A R APN 0 8 9 - 0 5 - 01 3 PARCEL SIZE O 2 4LAND USE APPLICATION # X OWNERNAME PETER KOCH _ PHONE 603-7583 v OWNERADDRESS 14464 E. PROPSECT PL CITY/STATE/ZIPLOCKFORD CA 95237 CONTRACTOR Delta pump RTn(^KTQN ARMATURE R MOTOR WORKS �t�13617r. 209-466-9Fi�5 _ CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 _ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS LICENSE D C-57 X C-61 0 D-09 ❑ Other GEOGRAPHICAL INFORMATION: Coordinates X CITY/STATE/ZIP NUMBER 724778 EXPIRATION DATE 08/ YT•-..—;,;- ---- INTENDED USE )PADomestic/Private ❑ Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring O'Soil Sampling/Characterization 0 Public Water System If different from Owner. a or ys em ame �nact Name or Phone Number rvnr nu°....... - - ,.ten ..o u mtjpicluemeni even u wen Alteration/Modification ❑ Other 0 Monitoring Well(s) # of wells 0 Soil Boring() # of borings # 9() 0 Geotechnical � s; ❑out -Of -Service Well OOut-Of-Service Well Renewal ❑ Cross -Connection Repair CIV, ❑ New Pum 0 Pump Replacement U�ump Repair - 0 Raise Well Casino CIV, Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other Sq4/ , IJ4 2 ':p 1jjlp Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/GravelAliDa�meter ❑ Conductor Casing in diameter / Conductor Casing Depth ft NOFpq FjvT,1� �, Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other RTM�jk?- - Grout Seat Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water 0 Bentonite (20% solids) ❑ Other Grout Placement Method 0 Pumped 0 Free Fall 0 Other ❑ Retardant / Accelerator (name) PEDESTAL installed By 0 Driller 0 Pump Contractor 0 Other 0 Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑Stove Pipe PUMP XVubmersibleo Turbine 0 Other HP ______J— Pump Set ft Standing Water Level 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 BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATIONMMMS----- SIGNED MINIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS TITLE CEO DATE 712 -111 R EP RTMENT USE ONLY Application Accepted By Date Area -L� Employee ID# Grout Inspection By n Date SPECIAL Well Permit 4e Pump Inspection By Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS 8/04/08 WELL /PUMP PERMIT