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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1r M JOB ADDRESS ! 3915 /^VLnc �- T e e. CITY/Zip d / 95j qD m CROSS STREET yr. v� b l�3--15 to 0 L� QIr !e A�P•N �/"7 PARCEL SIZE11, 9 BLAND USE AJ^PPLICATIO(N�e Q' A OWNER NAME M0 rl �4� I ber'1 56n PHONE r/� D�� ]0/^�7 7 7 m OWNER ADDRESS __s��. [._- CITY/STATE/ZIP CONTRACTOR Delta Pump_STncKTnN ARMATiJRF & MOTOR WORKS ff"@E. 209-466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 081 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization ❑ Public Water System If different from Owner: a er ystem ame on ac ame or one um er TYPE OF WORK ❑ New Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other ❑ Monitoring Weli(s) #of wells a Soil Boring(s) #of borings �� ❑ Geotechnical ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pum ❑ Pump Replacement .XPump Repair 0 Raise Well Casing A WELL CONSTRUCTION Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point ❑ Other SAN J&AQU/!y Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Siz �ftfter 0 Conductor Casing in diameter / Conductor Casing Depth ft TMENT Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic El Stainless Steel ❑ Other 4 Grout Seal Depth ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite(20%solids) 0 Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller C Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe IPU_MP SubmersibleA_`furbine ❑ Other HP Pump Set ft Standing Water I u 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M1AII141 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED _..._ :. 7......^`.._.. TITLE CEODATE 0 ,`. 'i✓r' ..+'.�' k,..c+r. t ♦t1•r.o4rtrYtf{r.•iw✓f�ti. .+�. r b.�P{•tb4 eryirr{� i� „ a.ir.11. jA►a} 4waA r ♦sb.+.a.. sa. r.l� y A.. sats.. a•+l .•.•.-.,,, ' i !lQ ,�-....-°u ♦.v� a�.a�+({s1 'W r. > .ar.. iii ,P •�..+iw, . uolte:)oT dwnd � • .ari e fig. ..'�1.' '. r. ••'MiN t{.{...•r� .. a. . r •• y•�.b r �b li.._.,,., �..�' •mow. _�. - T- y .. ♦. • e+..a..�•.i. .x . DEP RTMENT USE ONLY Application Accepted By Date Area Employee ID#� Grout Inspection By �\ Date �n SPECIAL Well Permit Pump Inspection By '�+� Date 2 ro WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Chec Amount Permit/ Codes Info B sh Remitted Date Service Re uest# Invoice# Well ID# EHD 43-06 8/04/08 WELL/PUMP PERMIT