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21 069 <br /> 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 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 19351 E Gawne Rd CITY/ZIP Stockton 95215 0 <br /> m <br /> D <br /> CROSS STREET Country 1�� 2 . 35 0 <br /> APN "' PARCEL SIZE LAND USE APPLICATION r# Q <br /> OWNER NAME Roy Medeiros209-401 -9683 m <br /> PHONE <br /> OWNER ADDRESS SAME CITY/STATEIZIP <br /> CONTRACTOR Delta Pump-STOC TON ARMATURE R MOTQR WORKS 11"Gh. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE)ZIP <br /> LICENSE . ❑ C-57 N C-61 ❑ D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/t� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Z Domestic/Private ❑ Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: ater ystem ame Uanlact Name or Hrione Number <br /> TYPE OF WORK ❑ New Well 0 Replacement Well 0 Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells U Soil Boring(s) #of bor4ngs k ofbu borings <br /> L Geotechnical <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> Wvew Pi imp KPump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rota ' 0 Air Rotary ry 0 Auger 0 Cable Tool ❑ Push Point ❑ Other - <br /> Proposed Well Depth ft Excavation 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 ❑ Plastic 0 Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) 0 Other <br /> Grout Placement Method D Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick nHO Christy Box ❑ Stove P�ipe � <br /> 1Pump �Submersible0 Turbine ❑ Other 3 HP Pump Set ft Standing Water Level ft <br /> N <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE tN ACCORDANCE WITH SA <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 COMPENSATION LAWS- <br /> MINrgu*_ 4 t[OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 9 2/1 /19 1 <br /> r <br /> M <br /> At <br /> Well is inside „i <br /> small metal <br /> S. <br /> 0 kt— <br /> AL '01V- . 4. <br /> �__ DE�'�MENT USE ONLY <br /> Application Accepted By �►/Yy 1 Date Area <br /> Employee ID#4U� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By ��N 1r,�OCl�a1l\ _ Date S WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS ft <br /> PEiii <br /> SC Received he Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />