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20817 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN -KF -FUNDABLE PERMIT <br />JOB ADDRESS 8900 CANEPA RD. <br />CROSS STREET_ <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />HILDRETH <br />MARCIA SALMON <br />SAME <br />k;ALL (ZU9) 9b3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY21P STOCKTON 95212 <br />_ APN 086-43-027 PARCEL SIZE 2 LAND USE APPLICATION # <br />PHONE 209 481 -7508 <br />CITY/STATE/ZIP <br />Delta Pump-.qTpCT<TnN ARMATURF & MOTOR WORKS II6GI>._ 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE . 0 C-57 X C-61 ❑ 0-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1G <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE IMmestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number 0311, v 0 A.�. <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) #of wells 0 SoilBoring(s) #of borings 0 Geotechnical #of borings -*LCE <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair NOV 1 4 20M <br />❑ New Pump ❑ Pump Replacement XlZump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION q0N COU <br />EWIDrilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool 0 Push Point ❑ Other H ALTw MENTAL <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 0 Steel 0 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe <br />PUMP ❑ mersible❑ Turbine 0 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 COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED �.,.s �.,_ TITLE CEO DATE <br />Application Accepted By <br />D PAR MENT USE ONLY <br />r <br />Date J0 <br />Area Employee ID# <br />Amount <br />Remitted <br />Grout Inspection By <br />Permit/ <br />Service Re uest # <br />v PECIA Well Permit <br />Well ID# <br />Pump Inspection By NMUA <br />Date I / I .S 1� <br />WAIVER Received <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth <br />fl <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received he <br />B as <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />O <br />/ <br />i f 31 <br />W Q'3� <br />8104/08 V V WELL /PUMP PERMIT <br />rr <br />m <br />D <br />a <br />C7 <br />m <br />m <br />va <br />m <br />