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17965 WELLIPUMP 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 li-'m INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> JOB ADDRESS 243015 P.- HTC,HWAY 4 CITY/ZIP PARMTNCTON ('A A5230 D <br /> Q <br /> CROSS STREET S_ f4r.W T TT APN1 97_0-)_()j 7 PARCEL SIZE 2C) - 2 AND USE APPLICATION# A <br /> m <br /> C' <br /> OWNER NAME JIM BOONE PHONE 209 886 5490 P <br /> OWNER ADDRESS SAME CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump_$Tn(,KTnN ARMATURE & MOTOR WORKS ff"Eh. 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 TA C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/16 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private 13 JrQgation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Uonact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement k Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point ❑ 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 Schad ❑ Steel ❑ Plastic 0 Stainless Steel ❑ Other <br /> Grout Seal Depth ft D Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br /> PUMP gXSubmersibleo Turbine 0 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 LICENSF IF <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT] AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE1 1 /6/2015 <br /> Take Highway 4 east. Entrance to the property is PUMP/WELL located approx. <br /> about 1.2 miles past S.Hewitt Rd..The sign post 14 ft from drive way and 77 ft. <br /> reads 24305 E.highway 4. No apn N for this from house. In front of a tree. <br /> address.Used 24241 E.Highway 4 for the APN N. <br /> ® HOUSE <br /> Row of trees on <br /> east side of <br /> driveway <br /> Entrance ' <br /> t Address sign post reads <br /> NJ <br /> ) �a1n5 <br /> ALTH <br /> S <br /> � 1 <br /> ), f DEPARTMENT USE ONLY <br /> Application Accepted By �� Date 't� (C'(t AreaEmployee iD# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By V Date 0 WAIVER Received <br /> Soil Boring lns ec`ti.on Date { nstructed Well Depth ft <br /> COMMENTSC�WI ,Vtn, t—� <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 84o WPxogt31 <br /> gas <br /> EHD 43-06 <br /> 8/04/08 <br /> J {/r � �" WELL/PUMP PERMIT <br />