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Z0636 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN-KEFUNDABLE HERMIT GALL (209) 953-7697 FOR INSPECTIONS <br />JOB ADDRESS 1 5 6 51 N. LOCUST TREE RD. <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY%ZIP LODI CA 95240 <br />CROSS STREET H -WY I? APN 0 51 -1 R_051 PARCEL SIZE 1 9�0 3LAND USE APPLICATION r# <br />OWNER NAME JAMES DECKER U1 1)L1 i. o J % PHONW 0 9 327 9007 <br />OWNER ADDRESS gAME CITYISTATE/ZIP <br />CONTRACTOR _ Delta Pump_4Tn(,KTnN ARMAT IRF & MOTOR WORKS ff"WE._209-466-9625 <br />CONTRACTORADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE 0 C-57 X C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBER 724778 ExPiRATIONDATE 08/1`% <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ranae Sention <br />INTENDED USE ADomestic/Private E Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner; a er ys em ame Contact Name or Phone um er <br />ivcw vven a mepracement vveu ❑ Well Alteration/Modification 0 Other <br />O Monitoring Well(s) # of wells 0 Soil Boring(s)# of borings # of borings <br />c7 Geotechnical <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />❑ New Pump C Pump Replacement XKump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool C Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel D Plastic 0 Stainless Steel C. Other <br />Grout Seal Depth ft C Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped 0 Free Fall C Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width It Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP V)&bmersible0 Turbine C Other HP _�Pump Set ft Standing Water Level ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN j <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 ._r=..r_.. TITLE CEO <br />DATE 7/3112018 <br />..... <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date O <br />Date <br />Date <br />Date <br />a1. b,, <br />Lj <br />Area <br />Employee ID# AZ4 _ "SP <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Chec Amount <br />Codes Info B Date PermiU <br />Remitted Service Re uest # Invoice # Well ID# <br />EHD 43.06 <br />8/04/08 <br />WELL /PUMP PERMIT <br />T <br />m <br />m <br />Q <br />a <br />m <br />m <br />y <br />