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18699 WELL/PUMP PERMIT <br /> SAN JOAQOIN 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 /> .I <br /> JOB ADDRESS 13833 N. ROYAL RD. cITYIZIP LOD I 95242 m <br /> CROSS STREET W. KINGDOM APN('�4-,;�—jL�O- 0 1 <br /> PARCEL SIZE2 4 •2 3 LAND USE APPLICATION# m <br /> y <br /> OWNER NAME LTMA RANCH PHONE 209 969 5225 <br /> OWNER ADDRESS 1 '14-1(; N_ THnR NTnN R D_ CITY/STATE/ZIP LOD I . 95242 <br /> CONTRACTOR Delta Pump-STnrKTnN ARMATURE & MOTOR WORKS ff"Q. 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 0 C-57 'N C-61 ❑ D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ DomesticlPrivateMrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Num5er <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Borings) #of borings 0 Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement Wump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ElSteel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mrx17 gal water <br /> ❑ Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible urbine ❑ 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 CONTRAC'rORS STAI'E LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED .-a r=+r i-.- TITLE C£0 DATE7—2 6—2 01 6 <br /> PUMP/WEU is located approx.442,27 ft.from <br /> N.Royal Road <br /> a . <br /> n <br /> s <br /> - 7 <br /> ..1" ':!• �;4.y ;'Std t <br /> y <br /> i <br /> Application Accepted By V _ Date Area Employee ID# 60< <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date ow�tm 4- WAIVER Received <br /> Soil Boring inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> q17� s'c� D.a� �oU�SS3 WPvo3galy <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />