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20816 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 4902 HILDRETH CITY/zIP STOCKTON 95212 D <br /> CROSS STREET N LLOYD LN APN 085-30-016 PARCEL SIZE <br /> .O6 LAND USE APPLICATION# m <br /> (n <br /> OWNER NAME DA_NNT TJJTC,.� PHONE Ur <br /> 9s�-5991 <br /> OWNER ADDRESS SAME CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump-4TnCKTnN ARMATURF. & MOTOR WORKS 110Q. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE . ❑ C-57 X C-61 0 D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/1q <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE IXDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ 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 ❑ 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 /> 0 Out-Of-Servicz Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> X New Pum `;Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size—' <br /> 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 bag15-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ 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. 1 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 /> ,,,,,MINIMIJ24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED -" <br /> y TITLE CEO DATE <br /> PUMP WELL IS LOCATED <br /> APROXIMATELY 138.84 <br /> FEET FROM RD. <br /> „ o Z F- <br /> c�Z <br /> .+ 1 Zia <br /> Z)Zw <br /> 00 <br /> .3Z <br /> �wW <br /> M <br /> HI I IPH 1 1 1 1 1 <br /> DEPARTMENT USE 0 N L Y q� <br /> Application Accepted By Date (� Area Employee ID# Vy <br /> Grout Inspection By nn n Date c PECIAL Well Permit <br /> Pump Inspection By rT 1Try NJ� Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date PermiU Invoice# Welf ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHO 43-06 <br /> 8104/08 WELL/PUMP•PERMIT <br />