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'- ✓ <br /> 19784 WELL/PUMP PERMIT <br /> SAN JOAQUIN 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 6120 W- DE RHAM�F.RRY Rn- CITY/ZiPTRACY 95304 m <br /> CROSS STREET CHR I SMAN RD.' APN PARCEL SIZE -R'LAND USE APPLICATION# Ste10 <br /> _ <br /> OWNER NAME JACK CROSE S(A f'Lj—) (1/1 Tr- PHONE 831 -0962 rr <br /> _ -4 <br /> OWNER ADDRESS SAME CITY/STATEIZIP m <br /> ;v <br /> CONTRACTOR Delta Pump_g2'QCI<TnN ARMATUgE & MOTOR WORKS XQ. 209-466-9625 ' o <br /> CONTRACTOR ADDRESS 646 S. California Street CITYISTATE/ZIP Stockton, CA 95201 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP t <br /> LICENSE 0 C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1 q p <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE X)Pomestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring O'Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical a of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ew Pump 0 Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP XDXSubmersible0 Turbine ❑ Other 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 COMPENS <br /> MINIM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 10/5/2017 <br /> P Y <br /> R G <br /> n n111 <br /> PUMP/WELL is located ' <br /> approx.20 ft.from white <br /> roof building. _ <br /> k � ¢ <br /> NOTE: <br /> ?,;:'n SET°c STA"!D!NG WATER LEVEL <br /> IS UNKNOWN UNTIL THE JOB IS DONE _ <br /> DEPARTMENT USE ONLY j� !J <br /> Application Accepted By Date (]" I' Area—V Employee ID# `"I�'1 t4i"6 <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date 2 21 ' WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received 0ecQD Amount Permit! <br /> Codes Info B Date Remitted Service Request# Invoice# Well ID# <br /> 43�0 Oso .s - w <br /> P US <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />