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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 JOB ADDRESS 53 Ca CITY/ZIP SSC 4uk i 952/5 M /A/ (J CROSS STREET Q•�I�7a Q- APN 1 q-'SFiQ'�� PARCEL SIZE ✓i l O LAND USE APPLICATION# X OWNER NAME L=Id�MA I M Cd PHONE 2c� I -3� �� N OWNER ADDRESS _S Q M P CITY/STATE/ZIP CONTRACTOR Delta Pump—QTnC'KTnN ARMATURP & MOTQR WORKS ff"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 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1� GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System 1!!! If different from Owner: Water ystem Name �ontaci Name or one Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells 10 Soil Boring(s) a of borings 0 Geofechnicaf a of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement Pump Repair ❑ Raise Well Casin WELL CONSTRUCTION Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Y Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PackJGravel Size ' in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft C Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mixf7 gal water j Bentonite(20%solids) 'D Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other Concrete Pedestal Dimensions:Width ft Length ft Thick in C Christy Box ❑ Stove Pipe PUMP ubmersible O Turbine ❑ Other HP Pump Set /VD_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 COMPENSATION LAWS, MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS _ SIGNED a TITLE CEO DATE .ASS Approximately 50 ft ±'w + from the street ` � 1, ter' ,� ;y �.• -w ,,,. � ,-; R � • �l.1:J U0 e e� EPARTMENT USE ONLY �QYYI� Application Accepted By Date 1 �� Area ( r Employee ID#—��A- Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date C `S ?G\� WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS WNe ' Gr�-�,y*!� 6 �G� �L ) i �° Iy�� D�tiN('g� PE SC Received hec Amount Permit/ Codes Info B Remitted j Date Service Re uest# Invoice# Welt ID# 3�3 $ } I , /in ;�Dg EHD 43-06 8/04/08 WELL/PUMP PERMIT