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;�irua Sim 5-1s11-7 <br /> 19397 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 /> Job ADDRESS 7280 E. KETTLEMAN LANE CITY/ZIP LOD I 95240 m <br /> D <br /> CROSS STREET IIOERL APN 061 -13-302 PARCEL SIZE 1 5 LAND USE APPLICATION# A <br /> M <br /> OWNER NAME KEN MIKAWA PHONE2 0 9 369-4916 <br /> N <br /> OWNER ADDRESS SAME CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump-4TQ('KTc)N AgmATjjgF & MO'T'OR WORKS 0"►I<`dQ. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> LLICENSEC <br /> PHONE <br /> ADDRESS CITY/STATE/ZIP t <br /> -57 K C-61 0 D-09 0 Other NUMBER 724778 EXPIRATIONDATE 08/11 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 0 Domestic/Private ",igation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: a er ys em ame Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings #or borings <br /> D Geotechnical <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 0 New Pump i4eumpRe lacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) 0 Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br /> PUMP XML Submersible0 Turbine C Other HP Pump Set ft Standing Water Level ft <br /> 1 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 COMPENSATI <br /> MINIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 4 <br /> /28/2017 <br /> I <br /> — l <br /> I <br /> PUMP/WELL is located approx. <br /> 200.75 ft.from the road.The little <br /> �4c shack is no longer there.it used to <br /> house the pump. <br /> E <br /> T HEALTH <br /> LES <br /> NOTE: I VEp <br /> PUMP SET& STANDING WATER LEVEL ?O" <br /> IS UNKNOWN UNTIL THE JOB IS DONE "° -- Q <br /> 'Hp f qL <br /> F�yp <br /> 10- Ln <br /> EPARTMENT US ONLY <br /> Application Accepted By Date Area-L � -�—�— Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date C WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth {{ <br /> COMMENTS <br /> PE SC Received CheAmount Permit/ <br /> Codes Into B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> o5a a X38 �, �3 �Z.00-���b-g W 003°1321 <br /> EHD 43.06 <br /> 8/04/08 WELL/PUMP PERMIT <br />