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20244 WELL/PUMP PERMIT <br /> SAN JOAQUIIII COUNTY ENVIRONMENTAL HEALTH DEPT 1368 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468.3420 <br /> NN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 1856 N Broadway clrr/ZIP Stockton 95202 m <br /> CROSS STREET <br /> Waterloo APN 143-25-003 PARCEL SIZE 5 . 20 LAND UAcres <br /> 1 <br /> SEAPPLI NrF <br /> Jason Altnowd -2 ni <br /> y <br /> OWNER NAME - PHONE u•' <br /> OWNER ADDRESS 122 River Pointe Circle Lodi , CA 95240 <br /> CITY/STATE/ZIP <br /> I <br /> CONTRACTOR Delta Pump ,TC1CXTnNA_ RMATURE & MOTOR WORKS Ef"Gh. <br /> X49-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE C C-57 X C-G1 0-09 C Other NUMBER 724778 EXPIRATIONDATE 08/t� <br /> GEOGRAPHICALINFOR:!ATION: Coordinates X Y Township Range Section <br /> INTENDED USE A Domestic/Private D Irrigation/Agricultural D Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: awr.ystem vanio <br /> Contic',Narne or Phone Numoer <br /> TYPE OF WORK New Well C Replacement Well 0 Well Alteration/Modification U Other <br /> G Monitoring Well(s) #or wells 0 Soil Boring(s) ""of bonnns II Geotechnical #orboringe <br /> C Out-O`-Service Well G Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump CXPump Replacement 0 Pump Repair Raise Well Casin <br /> WELL CONSTRUCTION <br /> Y ' <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 C Open Bottom D Gravel Pack/Gravel Size in diameter i <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic 0 Stainless Steel D Other <br /> Grout Seal Depth ft C Neat Cement(94 ib bag/5-10 gal water) r; Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) S Other <br /> (Grout Placement Method C Pumped 0 Free Fall 0 Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Purnp Contractor 0 Other <br /> Concrete Pedestal Dimensions:Width ft Length R Thick in Christy Box 0 Stove Plpe <br /> j PU61P X SubmersibleC Turbine :, Other 3 HP 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 /> MINIMUM// 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED <br /> --_--- _- __ __-- TITLE CEi) 4/25/10 <br /> r-- _ — --- DATE I <br /> rFeetrfro itely 70m Broadway <br /> +1 ;I �,• , <br /> p <br /> SAtV <br /> I 410- N.V �lI <br /> H�LTy pEP E T <br /> PA T M E N T�UZ Ej <br /> ApalGroun Accepted By Date tirea :m 'o a ID# <br /> = P� Y� <br /> Grout Inspection By Date Q�S� <br /> PECIAL Well Permit <br /> Pump Inspection By Datea WAIVER Received <br /> Soil Boring Inspection By Dato Constructed Well Depth ft <br /> COMMENTS <br /> Fes SC Received Ch Amount Permit/ <br /> I Info I BY Cash Remitted j Date Service Re uest# Invoice P Well IDI R <br /> `-g I —J <br /> EHO 43-OG <br /> 9/04100 WELL!PUMP PERMIT <br />