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f 20613 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 /> � uJ <br /> JOBADDRESS 5828 CARPENTER RD. _+ <br /> CITY/ZIP STCICKTA�L�5 1 5 m <br /> CROSS STREET S 3 OAK RD. APN 1 7 9-0 4-0 3 6 PARCEL SIZE 1 0 0 LAND USE APPLICATION# � <br /> �,p m <br /> OWNER NAME T.IIKF ORT . ;A (� �( � jl� Sh tr./�u l�l PHONE 598-6233 <br /> OWNER ADDRESS P.O. BOX 30321 CITY/STATE/ZIP STOCKTON CA 95213 <br /> CONTRACTOR Delta PmMR STIICKT0N ARMATURE R MOTOR WORKS ffg* - 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIPStockton. CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 0 C-57 X C-61 0 D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USEOmeStic/Private C Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System ame Uontact Name or Phone Number <br /> TYPE OF WORK ❑ New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> D Monitoring Wells) #of wells 0 Soil Sorin s #of borings Qf orings <br /> C Out-Of-Service Well 9( J 0 Geotechnical lr <br /> 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair R�C 1 ��T <br /> ❑ New Pump 0 Pump Replacement g)5gmp Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point ❑ Other ASG <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Grave i�®ga In givarneter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft ��4GTyRONMEN�Nn' <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Piasiic ❑ Stainless Steel ❑ C <br /> Grout Seat Depth ft C Neat Cement(94!b bag/5-10 gat water) 0 Sand Cement sack mix al water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall ❑ Other ❑ 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 0 Stove Pipe <br /> PUMP bmersibleO 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 LICENSE IS <br /> CURRENT AND ACTIV ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSAT N LAWS. <br /> MINIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO <br /> DATE7/24/2018 <br /> PUMP/WELL Is located in front of the <br /> W house approx.40ft.from the road. <br /> % <br /> 9� <br /> /�� E�PRTMENT USE ONLY <br /> Application Accepted By Date (/ Area Employee ID#� <br /> Grout Inspection By Date 4/SPECIAL Well Permit <br /> Pump Inspection By Date Z WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ec Amount permit/ <br /> Codes Info 8 Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> b- d OD f) <br /> EHD 43.06 <br /> 8104108 WELL/PUMP PERMIT <br />