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. T <br />20910 <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 <br />GALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 2546 P -enelie,m Turnpike CITY/ZIP__Stockton 95206 <br />CROSS STREET W 9th St APN 165-26-126 PARCEL SIZE 1. 5 2 LAND USE APPLICATION # <br />OWNER NAME Nathan Davidson <br />PHONE 209-627-5125 <br />OWNER ADDRESS SAME CITY/STATE/ZIP /10� ► �/ �� / <br />CONTRACTOR Delta Pumy GT()CKT0 N ARMATURE R MOTOR WORKS MQ. 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 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 724778 EXPIRATIONDATE 08/1� <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE q Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: a er ys em ame Contact Name or Phone Number <br />Tv � 11- 1111.. <br />.Vw VYG11 a 1ZeNiacement vven U wen Alteration/Modification <br />❑ Monitoring Wells) # of wells 0 Soil Boring(s) <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal <br />❑ New PumD ❑ Pumo Renlacemant XI Pum, P-;, <br />0 Other <br /># of borings ❑ Geotechnical # of borincP <br />❑ Cross -Connection Repair % A <br />0 Raise Well Casino REf <br />Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size. <br />❑ Conductor Casing in diameter / Conductor Casing Depth ftc/yV/ 'C <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel 0 Other �THDE <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped 0 Free Fail ❑ Other n Rata H—f / A-1 � <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br />C Concrete Pedesta) Dimensions: Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br />PUMP X Submersible❑ Turbine 0 Other HP 1 Pump Set 9 0 t ft Standing Water Level 2 3 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. 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 TITLE CEO DATE _1 1 /27118 <br />ARTMENT U <br />Application Accepted By � <br />7 <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />PE <br />ides <br />SC <br />Info <br />Received <br />B <br />Che Amo <br />as Remi <br />& <br />O � <br />G,X <br />�3/737 <br />Date -L-,—'1 t 0 <br />Date <br />Date _\ 1 <br />Date <br />Date I rerr <br />Service R <br />Employee ID#A&q-6P <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />#I Invoice # I Well ID# <br />ft <br />EHD 43-06 <br />8/04/08 WELL /PUMP PERMIT <br />N <br />m <br />rn <br />D <br />0 <br />v <br />M <br />M <br />