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17130 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 1 2 0 0 `�' a� } }/g�;} S CITY/ZIP 95391 m <br /> CROSS STREET_• `U, I .�(/uA,(�:J TV" APN 209-45-0 <br /> 3 3 PARCEL 504 8 _ d LAND USE APPLICATION# m <br /> OWNER NAME <br /> PHONE 234-1722 N <br /> OWNER ADDRESSU 4 _ CITY/STATE/ZIP. ySJZ�— <br /> CONTRACTOR Delta Pump PHONE 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 i <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 0 C-57 X C-61 D D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/1 6 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/PrivateI Igation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water Syst <br /> If different from Owner: Water System Name uomaCt Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 4 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connectlon Repair <br /> �1ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TIO <br /> Drilling Method 0 Mud Rotary 0 Air Rotary . 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 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 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack m1x/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> I Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br /> ❑Concrete Pedesta) Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP JcSubmersibleo Turbine 0 Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY C,CRTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOA00IN rOtjNTv ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT WiY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT,I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP WS. <br /> I NIMUIVI 24. HOUR ADVANCE NO'T'ICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CED DATE 2—.lam/—2 0 1 <br /> ZZ <br /> r <br /> -H <br /> DEPARTMENT USE ONLY <br /> Application Accepted y Dato Area Employee ID <br /> Grout Inspection By DatePECIAL Well Permit <br /> Pump Inspection Byl Date �� WAIVER Received <br /> Soil Boring Ins tion By - Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received _ he Amount Date Permit/ <br /> Codes Info B Cas Remitted Service Request# Invoice# Well ID# <br /> EHD 43-06 <br /> 8104108 WELL/PUMP PERMIT <br />