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20808 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN-KEFUNDABLE FERMIT (:ALL (209) 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br />Jos ADDREss1 6 4 9 W. HARNEY LANE CITY/ZIP LOD I CA 95242 <br />yN r <br />CROSS STREET_ BTWN LOWER SAC & XM3S T LANE 0 5 8 - 2 -PWA SIZE _ 1 . 0 3 LAND USE APPLICATION # <br />OWNER NAME NIK FARROS PHONE209 368-8625 <br />OWNER ADDRESS SAME CITY/STATEIZIP <br />CONTRACTOR Delta Pump--TnCxmnN ARMAm tR . & MOTOR WORKS Udf&. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE .❑ C-57 X C-61 0 D-09 ❑ Other <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 724778 EXPIRATION DATE 08/1 <br />Township Range_ Section <br />INTENDED USE RRomestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />O Public Water System <br />If different from Owner. Water System Narrm Con c ame or Phone Numoer <br />TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) #of borings D Geotechnical #of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair Pgy�yp�N <br />0 New Pum 0 Pum Replacement ❑NIm Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION Fq <br />. EI/P® <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Siz qU V * 14 ireter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel SoEV ah -18. <br />AN JOAQUIN COUNTY <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement HEALTIfinter <br />0 Bentonite (20% solids) 0 Other 1 � <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br />PUMP gkubmersibleo Turbine 0 Other HP �5_ 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 <br />MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO DATE 10/4/18 <br />I <br />W <br />EP RTMENT US 0N,{�LY <br />Application Accepted By c Date V <br />Grout Inspection By Date <br />Pump Inspection By Date \\ <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area akoo k Employee ID#� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />I <br />Im <br />D <br />0 <br />0 <br />m <br />m <br />en <br />rA <br />PE <br />Codes <br />SC Received <br />Info B <br />Check# Amount <br />as Remitted <br />Date <br />Permit/ <br />. Service Re uest # <br />Invoice # <br />Well iD# <br />l&�L? <br />; I �' IS <br />���Co <br />tHU 43.06 <br />8/04/08 <br />WELL /PUMP PERMIT <br />