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1 <br /> 19909 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 /> y <br /> JOB ADDRESS 7615 W. UNDINE RD- CITY/ZIP STnCKTQN 95206 D <br /> 0 <br /> CROSS STREET W. WING LEVEE RD. APN_ 189-20-005 PARCEL SIZE_LAND USE APPLICATION# m <br /> m <br /> OWNERNAME MARCIA SALMON PHONE 463-2822 <br /> OWNER ADDRESS 8 9()0 GA �w � CITY/STATE/ZIP STOCKTON 95206 <br /> CONTRACTOR Delta Pump-S.TnrxTnN ARMATURE & MOTOR WORKS M&h. 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 XC-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATIONDATE 08/1� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Rc&estic/Private 0 Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Gontact Name or Phone Number <br /> TYPE OF WORK C New Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring #of borings #of boring <br /> s) ❑ Geotechnical n <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair z '� <br /> )CXNew Pump ❑ Pump Replacement 0 Pump Repair ❑ Raise Well Casing 'm N <br /> WELL CONSTRUCTION y <br /> F— <br /> Drilling Method 0 Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point ❑ Other "= N <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in meV <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seat Depth ft 0 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor 0 Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP XCXSubmersibleo 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED i~- TITLE CEO DATE 1 0-1 6=2011 7 <br /> ., r.:_ . d ,, , <br /> PUMP/WELL Is located approx.91 ft I ; - . - , - �� <br /> �6 <br /> from edge of the road,Under the w Ya <br /> r, �! <br /> trees. <br /> JA <br /> w p .* � t <br /> f.. <br /> _ : <br /> ,;.,t- ,,_� yr �►,'_ � <br /> Oct <br /> NOTE: <br /> PUMP SET&STANDING WATER LEVEL <br /> IS UNKNOWN UNTIL THE JOB IS DONE <br /> DE ARTMENT USE NLY <br /> Application Accepted By-�� Date l Area -1 Employee ID#A��/�'l�1�y�,/��/, <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> Codes Info 8 Date Cash Remitted Service Request# Invoice# Well ID# <br /> 0031 ,� <br /> EHD 43.06 <br /> 6/04!08 WELL/PUMP PERMIT <br />