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21 01 6 <br /> WELL/PUMP PERMIT <br /> SAr 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 /> 0 <br /> JOB ADDRESSs aanWi-ng Levee Rd cITY/zIP Stockton 95206 m <br /> D <br /> 0 <br /> CROSS STREET Undine APN 1 8 9-2 3-0 2 3 PARCEL SIZE 24 0 . 912ND USE APPLICATION# X <br /> m <br /> Cn <br /> OWNER NAME Marl c) ,Ta=11,-4 PHONE 209-61 2-1 477 y <br /> OWNER ADDRESS gAMF. CITY/STATE/ZIP �A 16-L — \\C�\ <br /> CONTRACTOR Delta Pump-_qTnf 'KTn T ARMATTIRF & MOTOR WORKS 11"U. 209-466-962 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 1 <br /> LICENSE . ❑ C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE X, omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: a er ystem ame on ac ame or one um er <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ��►" <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of boringsL1 Geotechnical ofborn9s*6t� <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Re lacement Pump Repair ❑ Raise Well Casing2019 <br /> 01 WELL CONSTRUCTION E'T'V UW C <br /> Drilling Method ❑ Mud Rotary 01Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other NE'gLT�ONA�F/VTUN <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in iAt$r <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft 7 Neat Cement(94 Ib bag/5-10 gal water) G Sand Cement sack mixR gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller C Pump Contractor ❑ Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other Ha _2 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. 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 /> —_—'—WN1N94 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED �` �� TITLE CEO DATE S <br /> The pump is <br /> approximately 75- <br /> 80 ft from home y <br /> low <br /> � 2 <br /> i <br /> EP RTMENT USE NLY <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date SPCIA L WeII Permit <br /> Pump Inspection By � ) JI (/A�W') Date_ I t WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount Permit/ <br /> Codes Info B as Remitted Date Service Request# Invoice# Well ID# <br /> I <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />