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20791 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT I:ALL LUy y5:3-1bUt FOR INSPECTIONS tXPIKtS 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 22675 ELLIOTT RD. CITY/ZIP ACAMPO CA 95220 <br />CROSS STREET BETWN BENNDORE & A&LT IER 007-1 7 - 01P7RCEL SIZE 'I _ 19 LAND USE APPLICATION # <br />OWNER NAME -R EQ C 0 E PHONE 334-9249 <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR Delta Pump-gTprKTnN ARMATURE & MOTOR WORKS E0 0. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE . 0 C-57 X C-61 <br />PHONE <br />CITY/STATE/ZIP <br />0 D-09 ❑ Other NUMBER 724778 EXPIRATIONDATE 08/t� <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y Township Range Section <br />INTENDED USE ❑ftmestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />1 YPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical aQ: %' 7' ❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair —••kec,�'/1 /� <br />0 New Pum m Replacement ❑ Pum Repair 0 Raise Well Casingpj; <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other SAN ill.2018 <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravi", / iNCID(f <br />Ap/in diameter / <br />Well Casing Diameterctor Carlin Thickness/Gauge/ASTM Sched Conductor Casing Depth❑Steel ❑Plastic ❑Stainless Steel F1 Ot �Ep;9/? Ve T Y <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag15-10 gal water) ❑ Sand Cement sack mixl7 gat water <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other ❑ Retardant / Ar nPlPratnr (nnmal <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br />IL ❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />I 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. 1 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— <br />.•-�'- TITLE CEO <br />DATE 9 1271201 A <br />EP RTMENT U E LY <br />Application Accepted By Date �l <br />Grout Inspection By Date <br />Pump Inspection By k O�rnV\ Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Areae Employee ID#� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />hec <br />Cash <br />Amount <br />emitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />3Is <br />7 <br />it I3I� <br />X10,5 <br />vo <br />8104/08 WELL /PUMP PERMIT <br />rn <br />1 <br />m <br />D <br />0 <br />C7 <br />X <br />m <br />N <br />