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RECEIVED <br /> 20333 WELL/PUMP PERMIT MAY 0 7 2018 <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 YEtA d&W 4"ik&TH <br /> !/'CES 0 <br /> Job ADDRESS 10630 T. R T _g _� CITY/Zip m <br /> D <br /> GROSS STREET__ O <br /> 8 MILE R 17 APN_��3-1 — PARCEL SIZE ND USE APPLICATION# CY <br /> m <br /> OWNER NAME ---JOHNZr !. PHONE 9�1 _Q'J n <br /> OWNER ADDRESS 12022 F ('OM S TIDR n PAc� ice" <br /> -C Kt'� CITY/STATE/ZIPSTC) KTC1N CA- 5212 <br /> CONTRACTOR Delta Pump STOC•KTON ARMATURF $ MOTOR WORKS ff"Gh. 209-466-962 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE ❑ C-57 X C-61 0 D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/1_1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE �ffomestic/Private C Irrigation/Agricultural C Industrial ❑ Water Quality Monitoring O Soil Sampling/Characterization <br /> C Public WaterSystem <br /> If different from Owner. Water System Name —11-1 ame or one umber <br /> TYPE OF WORK G New Well 0 Replacement Well 0 Well Alteration/Modification ❑ Other <br /> C Monitoring Well(S) #of weUS iJ Soft Bonn 5 #of borings ❑ Geotechnical of borings <br /> 9O <br /> Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connection Repair <br /> ❑ New Pump a Pump Replacement 0 Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool O 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 Sched O Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seat Depth ft ❑ Neat Cement(94 lb ba915-10 gal water) ❑ Sand Cement sack mixl7 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 0 Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box O Stove Pipe <br /> PUMP ubmersible0 Turbine O Other HP PurnP Set <br /> 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 I AM 1N COMPLIANCE WITH <br /> WORKERS COMPENSATtO <br /> MINIMU ALL <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 5/3/7 0 1 8 <br /> t _ i <br /> PUMP/WELL Is located east side next . <br /> to the house. <br /> N __.... + <br /> L H E <br /> + <br /> I <br /> D PA TMENT US ONLY <br /> Application Accepted 9y Date <br /> Area Employee ID#_� �� <br /> Grout Inspection 8y` 1 Date iSPECIAL Well Permit <br /> Inspectiop.By fl s) i / <br /> Date WAIVER Received <br /> Date <br /> Soil Boring Inspection By t<<I I <br /> COMMENTS WAIVER <br /> Well Depth ft <br /> PE SC Received Codes Amount Info g Date Permit/ <br /> ash Remitted Service Re uest# Invoice# Well ID# <br /> EHD 43.06 <br /> 8/04106 <br /> WELL/PUMP PERMIT <br />