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T f 1991 WELL/PUMP PERMIT f 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 fn JOB ADDRESS 0 5 0 E. MORADA LANE cmytziP STOCKTON 95212 m D CROSS STREET HICKORY APN 085-17-004 PARCEL SIZE 1 . 01 LAND USE APPLICATION# X y J Ch OWNER NAME _RAyp'�EL1,AR PHONE 608-1 7 6 5 OWNER ADDRESS SAME CITY/STATE/ZIP CONTRACTOR Delta Pump-STOCKTON ARMATURE & MOTOR WORKS MQ. 209-466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP tQ LICENSE 0 C-57 X C-61 0 D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/I p GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE RRomestic/Private ❑ Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization 0 Public Water System If different from Owner: Water System ameon ac Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other 0 Monitoring Weil(s) #of wells 0 Soil Borin9( )S #of borings 0 Geotechnical #of borings 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement )Mump Rep air 0 Raise Well Casing WELL CONSTRUCTION i Drilling Method 0 Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool 0 Push Point 0 Other Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic 0 Stainless Steel 0 Other Grout Seat Depth ft 0 Neat Cement(94 Ib ba915-10 gal water) 0 Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) 0 Other Grout Placement Method 0 Pumped ❑ Free Fall 0 Other 0 Retardant/Accelerator(name) PEDESTAL installed By ❑ Driller 0 Pump Contractor 0 Other C Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe PUMP Xg Submersible❑ Turbine ❑ Other HP 1 Pump Set 1 ft Standing Water Level S 3 ft I HEREBY CERTIFY THAT 1 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 COMPENSALAWS. MINIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE CEO DATE 1 1 /29/1 7 PUMP/WELL IS BEHIND THE HOUSE UNDER THE TREES. ffiq } FF I I I .r 'r My p M t?lJ 4 u Z44— —± 1 —1. .I I I I v,TMENT USE O/N LY Application Accepted By I Z Date Area Employee ID#� Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Amount Permit/Codes Info B Remitted Date Service Request# Invoice# Well ID# EHD 43-06 8/04/08 WELL/PUMP PERMIT