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t� ` 20714 WELL/PUMP PERMIT SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn JOB ADDRESS 1020 METTLER RD. CITY/ZIP LODI 95242 m D CROSS STREET LOWER SACRAMENTO ROO 5 3–QA–L2 7 PARCEL SIZE 6_ 13 LAND USE APPLICATION# A m OWNER NAME DARRIN COE PHONE209 625 6769 OWNER ADDRESS SAME CITY/STATE/ZIP CONTRACTOR Delta Pump_STprxTON ARMAT IRF & MOTOR WORKS M*Gh. 209-466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE . ❑ C-57 TS C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1� GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE X}Qomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner. Water tiystem Name L;ontact Name or Phone Number TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings 0 Geotechnical #of borings 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair 0 New Pum mp Replacement 0 Pump Repair 0 Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel 0 Other Grout Seal Depth ft 0 Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix[7 gal water ❑ Bentonite(20%solids) 0 Other Grout Placement Method 0 Pumped ❑ Free Fall 0 Other ❑ Retardant/AcceJerator(name) PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe PUMP bmersible❑ Turbine 0 Other HP q, Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATIO MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED— TITLECEO DATE 9/4/1 R PUMP/WELL IS JUST WEST OF THE POOL if .. 1 s�. P TMENT U E ONLY Application Accepted By Date �� Area-14—le-11Employee ID# Grout Inspection By Date {� SPECIAL Well Permit Pump Inspection By Date 3 J IU� WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS �ns C, PE �.6 Received hec Amount Date Permit/ Invoice# Well ID# Codes a fm B Cash Remitted Service Request# EHD 43-06 '- 8/04/08 WELL/PUMP PERMIT