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lea <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazolton Avenue-STOCKTON CA 95205.6232-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CAL! 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �I'''lf ���yyy111 /�' <br /> JOB ADDRESS 7!�300 1t' M CITY/ZIP -77n q 50 7 D <br /> CROSS STREET a 1 iZ e• APF! C�I ��(^ �' PARCEL SIZE-.-AND USE APPLICATION�1, m <br /> OWNER NAME �hm P-�.-1 A U S p i nA PHONE��J <br /> OWNER ADDRESS!il�L`( & � dry aw <br /> CITY/STATE/ZIP r4✓ <br /> CONTRACTOR Delta Pnlnn 'fnr:- PHONE—(2[19)466-9625 C(DPY <br /> CONTRACTORAODREss 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C C-57 AC-61 0 D-09 ❑Other NUMBER 10554 3 4 EXPIRATION DATE 8 L 1 6 L 2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE XDomestic/Privale 0 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Waler System <br /> If diffarant from Omer. Wotor 6YSWM NOMG contOlt N=0 or ono M.D.1 <br /> TYPE OF WORK Z]New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> Monitoring Well(s) S of veils Z!Soil Boring(s) i of boring' 0 Geotechnical a of bodngs <br /> Out-Of-Service W II C Oul-Of-Service Well Renewal 0 Cross-Connection Repair <br /> New Pum <br /> ump Replacement 0 Pump Repair Raise Well Casing <br /> WELL CONSTRUC N 11 <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point LI Other <br /> Proposed Wall Depth ft Excavationin diameter U Open Bottom n Gravel Pack/Gravel Size in diameter <br /> n Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad o Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal DDpih fi 0 Neat Cement(94 Ib baWS-10 gat water) 0 Sand Cement sack mix/7 gal water <br /> I:I Bentonite(20%solids) 0 Other <br /> Grout Placement Method (7 Pumped ❑Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> 0 Concroto Pedesta)Dimensions:Width it Length R Thick in 0 Christy Box ❑Stove Pipe <br /> PUMP Submersible0 Turbine ❑Other HP—_V' Pump Set it Standing Water Level it <br /> I HEREBY CERTIFY THAT 1 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 COMQENUDON LAWS. <br /> NIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 10 .7-J 4 <br /> r <br /> — —._ I -_ <br /> r <br /> F` r <br /> + }! -�. <br /> Nor <br /> // `` Q• <br /> T M E N T U E N L Y J,Q <br /> Application Accepted By w -..� Dale Arca Employee ID#jj��""r <br /> Grout Inspection By Date SPECIAL WHIZ Permit <br /> Pump Inspection ByDate-l WAIVER R curved <br /> Soil Boring Inspection By Dato Constructed Well Dopth ft <br /> COMMENTS <br /> PE SC Receivedhec Amount Date Permit' Invoice 0lS Wall ID// <br /> Codes Info B sh Remitted Service Raguest/F <br /> 400 WP0040�254 R olj <br /> roll <br /> F /0 <br /> EHD J3•eu <br /> W04108 FROG 0 .,JELLIPU%IPPERMIT <br /> O�y��ycOG J <br /> iP�1>ccq�tijy <br />