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r <br /> • • • 17490 `SELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-.STOCKTON CA 952056232 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT (;,ALL(209) 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> U) <br /> :I <br />€ JOB ADDRESS 29581 S. KOSTER RD, CITY/ZIP VERNALIS 95304 > <br /> c <br /> CROSS STREET L I NNE RD. AP N 2 5 5-2 7-0 2 0 PARCEL SIZE-1-41-.-840 USE APPLICATION# <br /> n" <br /> OWNER NAME RR,T FARMS PHONE 408-191 -$401 <br /> OWNER ADDRESS 488 PAGOSA WAY CITY/STAT-7/ZIP FREMONT CA 94539 <br /> CONTRACTOR Delta Pump PHONE 209-466-9625 <br /> CONTRACTORADDRESS 646 S. California Street CITYISTATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PRONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE 0 C-57 C-61 0 D-09 ❑ Other NUMBER 724778 EXPIRATION DATE_08A 6 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private RRrigation/Agrlcultural 0 Industrial ❑ Water Quality Monitoring 0:Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water 6ystem Name ------C-6—nFaqt Name or Phone Nlimt5er <br /> TYPE OF WORK ❑ New Well ❑ Replacgement Well 0 Well Aiteratlon/Modificatlon 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) 9 of borings ❑ Geotechnical i/of borings <br /> ^ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> .dew Pump *ump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> I <br /> Drilling Method ❑ Mud Rotary 0 Air Rotary . 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth ft Excavatlon 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 ❑ Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bag15-90 gal water) ❑ Sand Cement _sack mW7 gal Water <br /> ❑ Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 PWmped 0 Free Fall ❑ Other ❑ Retardant/Accelerator;(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width it Length ft Thick in o Christy Box ❑ Stove Pipe <br /> PUMP )Mubmersible❑ Turbine 0 Other HP--4-a_ . Pump Set It Standing Water Level it <br /> I HEREBY CERTIFY THAT I HAVE PRE-PARED 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 COMPENS <br /> :7MJINIIVI 24 HOUR ADVANCE NOTICE: REQUIRED FOR INSPEC(IONS <br /> SIGNED TITLE CEO DATEI+ <br /> 6/4/2015 <br /> q <br /> --, <br /> SNI F <br /> r yK/T/ :c/ R <br /> I <br /> 1 DEPARTMENT US ONLY <br /> Grout Inspection ByMpfe SPECIAL Well Perrnit <br /> Pump Inspection B ate WAIVER Received <br /> Soil Bor(ng inspon By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> Codes Info By Remitted Date Service Request# Invoice# Well ID# <br /> 4 zz Mo3�qq2 <br /> EHD 43.08 <br /> 8/04/08 WELL/PUMP PERMi r <br />