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` 20661 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 /> LA <br /> JOB ADDRESS 1 3 3 RAYLOW AVECIS/ZIP MANTECA, CA 95336 m <br /> D <br /> CROSS STREET YOSEM I TY APN 223-34-030 PARCEL SIZE 0.38 LAND USE APPLICATION# z <br /> cn <br /> OWNER NAME_ urniniTnir / }(uy p —�Q.I)/}// PHONE 2O9 663-5968 "? <br /> OWNER ADDRESS SAME CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump—STnr-KTnN ARMATi1RF. & MOTOR WORKS (10fik. 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 X C-61 D D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private CktkTigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water 6ystem Name Contact Name or Phone Numner <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring #of borings <br /> Boring(s) ❑ Geotechnical #of b <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair R�C 4 A& <br /> ❑ New Pum mp Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point ❑ Other 1 <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Si e ,1n dia <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft E9(T ROH hCp <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other UH <br /> Grout Seal Depth It ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixl7 g Fer <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> Pu MP " ubmersible❑ Turbine ❑ Other HP 1 - ri 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSAT <br /> MINIM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO <br /> DATE $/']�1 <br /> Pump/Well is located on the <br /> back of the housep near <br /> atio ; <br /> i <br /> the Jacuzzi. ►1 <br /> 1' <br /> ., <br /> p <br /> s - <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date U (y Area 1 rtEmployee ID# <br /> Grout Inspection By Daterr�� SPECIAL Well Permit <br /> Pump Inspection By ` Date Q oc WAIVER Received <br /> Soil Boring In ection By Date Constructed Well Depth ft <br /> COMMENTS 02 HtLB �icCQY� �4c( U r I b fPIP�J�f e 1_ <br /> —yt <br /> PEFOS <br /> Received a Amount Date Permit/ <br /> Codes B Remitted Service Request# Invoice# Well iD# <br /> y 3 3/.Z�/ 8 <br /> Lzpoo :�)$a, <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />