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WELL/PUMP PERMIT IV <br /> SAN JOAoum COUNTY E ��� <br /> NvtRONMENT,4t.HEALTH DEPT 4868 East kazelton Avenue-STOCKTON CA 95205$232 -(209)468,34 <br /> NON-REFUNDABLE PERMIT CALL 2209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7 51) 5 /�N f DT 1 n i np- R U CITy/ZIP 5+oc ,-4-on 951 k <br /> CROSS S7 REET�h r✓r o K P R APN_O U"19 <br /> -32 9 PARCEL SQP&3LAND USE APPLICATION# c <br /> OWNER NAmE R 4 S-5 e 4 -14 0 PHONE62 3 q- 6 <br /> OWNER ADDRESS Vc CIT Y/STATEMP <br /> CONTRACTOR Delta F=V_cTnry PnN ARMATLIRF & MOTOR WORKS 9iD361:._209-46b-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CRY/STATEMP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUSCONTRACTOR ADDREss CITY/STATE21P <br /> LICENSE . 0 C-57 X C-61 0 D-09 O Other NUMBER .72477$ ExputAnON DATE 08/1A <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> tNTENDED USE 0 Domestic/Private 0 Irrigadon/Agricultural O Industrial O Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If�Iferam Bom 02 Water ys ams uontad Narde or Ffmm Nu(noer <br /> TYPE OF WORK ❑ New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitorings Wells) #of wells 0 Soil Boring(s) #01 bo rr�p 0 Geotechnical <br /> 0 Out-WService Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑ New PumD 0 Pump Replacement XpumpRepair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter O Open Bottom 0 Gravel Pack/Gravel Size Y ti to diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 0 Steel O Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(941b bag(6.10 gat water) 0 Sand Cement sack mlx/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall O Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By O Driller 0 Pump Contractor 0 Other <br /> O Concrete Pedestal Dimensions:Width It Length ft Thick In 0 Christy Box 0 Stove Pipe <br /> PUMP 0 SubmersibleO Turbine 0 Other 7, 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.I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> _ MINIIVI$M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS J <br /> SIGNED ..�- ... r ' DATE <br /> -- — TITLE_ CEO <br /> 11 1 M <br /> --'qr <br /> Y <br /> ALT MENT US NLY <br /> Application Accepted By Date Area Employee ID#,4�'�► _ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By \D_JL�w Date l N ZD I'lr3 WAIVER Received <br /> Sol[Boring Inspection By Date <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> Codes Info B Remitted Date ServiceRequest# Invoice# Well ID# <br /> LD 4J3a3q <br /> EHD 43-M <br /> eiov 9 WELL/PUMP PERMIT <br />