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20877 <br /> 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 /> JOBADDRESS 2370 T,FARNFD AVE ciTr21PSTOCKTON, 95205 m <br /> D <br /> CROSS STREET-MA$_I POSA APN 173-02-015 PARCEL SIZE 0 • 8 7 LAND USE APPLICATION# M <br /> m <br /> OWNER NAME nnNNA cTA _nMA PHONE 209-937-0596 <br /> OWNER ADDRESS SAME CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump_.TnrT<TnN ARMAT IRF & MOTOR WORKS ffAQh. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE . 0 C-57 X C-61 ❑ 0-09 0 Other NUMBER 724778 EXPIRATIONDATE 08/t� <br /> GEOGRAPHICAL INFORMATION: Coordinates XY Township Range Section <br /> INTENDED USE X Domestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. a er ys em ame Contact Name or Phone um er <br /> TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) 0 Geotechnical <br /> 5 #of borings #of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement [Wump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Li Bentonite(20%solids) u Other I <br /> Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP EXSubmersibleD Turbine 0 Other HP rPump Set 1 2 5 ft Standing Water Level 4 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 /> 4 I"IOI,JR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> TITLE CEO DATE <br /> t <br /> MAIN HOUSE AND IF <br /> BACK DRIVWAY <br /> DRIVEWAY USE THIS DRIVEWAY TO REACH PUMP <br /> PUMP WELL IS LOCATED IN BACK <br /> OF THE GARAGE.UNDER LEAN TOO. <br /> APROXIMATELY 150 FT FROM RD. <br /> 0 O,` O r: <br /> �Ie 1 <br /> f91 <br /> DEPARTMENT US O LY <br /> c <br /> Application Accepted By Date Area _ Employee ID#,�� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date 12- 12 7.0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received he Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> EHO 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />