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28326 WELL/PUMP PERMIT <br /> SAN;IOAOUIN 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 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 18704 F ('nPPF>?nDnT TS D CITY/ZIP T.TNnFN (-A 9S2R(; m <br /> D <br /> CR055 STREET DR A T RF) APN A3 - j`•��,.�J PARCEL SIZE 1 LAND USE APPLICATION � <br /> m <br /> OWNER NAME JEANS TE3 SA NGU941L�_ PHONE 483-4921 <br /> OWNER ADDRESS SAME CITY/STATE/ZIP J 1 `( S L o 3 TT—u4 <br /> CONTRACTOR Delta Pump STOCKTON ARMATURF & MOTOR WORKS 1144Q-209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP -_Stockton. CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE 0 C-57 X C-61 0 D-09 0 Other NUMBER 724778 EXPIRATION DATE 08 1 p <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural C Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> C Public Water System <br /> If different from Owner: Water bYStern Naine —Wcl Name or one Number <br /> TYPE OF WORK C New Well ❑ Replacement Well 0 Well Alteration/Modification ❑ Other <br /> O Monitoring Well(s) #of wells O Sof(Bonn s #of borinps # s <br /> g( 1 ❑ Geotechnical <br /> C Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repaircer <br /> ew Pum2 C Pump Replacement 0 Pump Repair ❑ Raise Well Casin <br /> WELL CONSTRUCTION ,AqL <br /> Drilling Method ❑ Mud Rotary C Air Rotary C Auger 0 Cable Tool ❑ Push Point ❑ OtherFj <br /> ry/ , <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Grave I Size. UOQ�In I ter <br /> ❑ Conductor Casing in diameter ! Conductor Casing Depth ft yEgZT/''►�//��o�JNCO <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel D Plastic ❑ Stainless Steel C Othel'FA Fh7,11 <br /> Grout Seal Depth ti 0 Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement <br /> sack mixINAIJOvater <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 0 Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible0 Turbine C Other <br /> HP Pump Set ft Standing Water Level ft <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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEA}5&n0NJ <br /> MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO <br /> DATE 4.17 n 1 R <br /> - <br /> PUMP/WELL is located to the shed. <br /> TAL 11 <br /> H <br /> EP RTMENT USE O LY <br /> Application Accepted By Date Area �� �� <br /> Employee IDft&* a <br /> Grout Inspection By n Date SPECIAL Well Permit �-�� <br /> Pump Inspection By >> Iv� Date <br /> Soil Boring inspection By WAIVER Received <br /> Date <br /> COMMENTS Constructed Well Depth ft <br /> PE Sc Received ec Amount <br /> Codes InfoPermit/ <br /> B Remitted Date Service Re nest# Invoice# Well ID# <br /> EHD 43-06 <br /> 8/04/08 <br /> WELL/PUMP PERMIT <br />