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21 048 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 1 YEAR FROM DATE ISSUED <br /> 1 JOB ADDRESS <br /> 224 :76 E. Setif f f Rd CITYIZIP poral nn 95"420 m <br /> CROSS STREET_Van Allan APN 5� �e PARCEL SIZE 1 5 8 LAND USE APPLICATION# <br /> OWNER NAME Wagner Dairy PHONEa e q`6�r2�r 1 q m <br /> OWNER ADDRESS Same CITY/STATE/Z1P <br /> CONTRACTOR Delta Pump GTl1C_K_TnN ARMAT17RP & MOTOR WORKS 1EAQ. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE . O C-57 QST C-61 ❑ 0-09 0 Other NUMBER 724778 EXPIRATIONDATE 08/1� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 0 DomestiGPrivate O�rrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: a er ys em ame Uunlaui Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well O Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells O Soil Boring(s) #of borings) O Geotechnical #°fb°""s s <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑ New Pum O Pum Re iacement um Re air O Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other x <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 0 Steel O Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) O Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall 0 Other O Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length �ft ck in �O.Chrls�ty.Bo,�D.St,,e�P�jpe <br /> PUMP Submersible❑ Turbine O 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT <br /> .t AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED ".'..ua..`.-`'_ .............: --"�— <br /> TITLE CEO DATE_21$L_n 1 9 _ <br /> tram <br /> r f" <br /> F704U- .` 0.Yf`� r •l7 �Y 1 <br /> I <br /> tic, U' <br /> ,,,, g <br /> - ILI . ►- <br /> :. 1� LIJ Z(L <br /> 1 17-1 <br /> Application Accepted Byw� ""f i <br /> Date Area Employee lurkL�40 <br /> Grout Inspection By Date S EC AL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Q3 j Z C)\A Constructed Well Depth <br /> COMMENTS ft <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Weft ID# <br /> 3Do(AS2-1 YvODS rl D-- <br /> EHD 43-06 <br /> 8/04/06 WELL/PUMP PERMIT <br />