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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT #13867 600 E.Main Street-STO&TON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> �/ 4 I <br /> JOB ADDREMs Ey K( rrrrrK ,r, CyTY/ZtP Stockton 45215 i k <br /> CROSSSTREET Gillis Road APN 103-060-13 PARCELSIZE LAND USE APPLICATION ' <br /> OWNER NAME Roger & Maria Casillas . PHONE . 465-21-38 <br /> I <br /> o%vNERADDREMs P.6. BOX 5779 -- - - Ctrr/STATtvzrP Stockton CA 95205 <br /> _ _ I <br /> CONTRACTOR Delta Pum _ _ - PHONE 209-466-2.625 <br /> CONTRACTOR ADDRESS 646 S. California Street clnr/STATE/ZrP Stockton, CA 9 203 <br /> SUBCONTRACTOR PHONEi <br /> SUBCONTRACTOR ADDRESS CPfY/STATFJZIP <br /> LICENSE OC-57 XTG61 OD-09 ❑Other NUMBER 724778 EXPIRATIONDATE 08/12. <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Stetson <br /> i <br /> INTENDED USE 3DomCs1icJPrivatc O lrrigation/Agricuirural O Industrial ❑Water Quality Monitoring O Soil Sampling/Characterization <br /> n- t PUN i-Water System;:. - _ c _�. _ - - - _ <br /> If diB2rent tram Owocr esu yuan am ouuct unc w M—C um <br /> TYTE QFWOFH O New Well O Replacement Well O Well Alteration/Modification ❑Other <br /> O Monitoring Wtll(s) #of wells O Soil Boring(s) a of boriagr O Geotechnical a°t borings <br /> O Out-Of-Service Well O Out-Of-Service Well Renewal O Cross-Connection Repair Q <br /> O New Pump M Pump Replacement O P'ump Repair <br /> WELL CQ:tSTR CITON <br /> Drilling Method ❑Mud Rotary ❑Air Rotary O Auger A Cable Tool O Push Point O Other <br /> t Proposed Well Depth fl Excavation in diameter O Open Bottom O Gravel Pack/Gravel Size in diameter , <br /> 11 Conductor Casing in diameter / Conductor Casing Depth- ft <br /> Well Casing Diamcler_in ThicknessJGauge/ASTM Sched. ❑Steel O Plastic O Stainless Steel 12 Other <br /> Grout Seal Depth --ft El Near Cement(94 A bag/J-l0 gal water) O Sand Cement .ruck mtr/7 gal water <br /> ❑Bentonite(20'/solids) O Manufacturer Spec%.solids % Name O Specs on File O Specs Submitted i <br /> Grout Placement Method O Pumped D Free Fall O Other O Retardant/Accelerator(name) <br /> t'EPESi , Installed By O Driller O Pump Contractor O Other <br /> O Concrete Pedestal Dimensions:Wldth fl Length ftThick in ❑Christy Boa ❑Stove Pipe ! <br /> LL�1C Mubmersible O Turbine O Othu HP 1 Pump Set 146 it Standing Water Level fl <br /> i I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL DE DONE IN ACCORDANCE WITH SAN <br /> II JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULA'T'IONS. 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 COhtPENSATION LAWS <br /> <— '1124 HOUR ADVANCE NOTICE.REQUIRED FOR INSPECTIONS --- �-- -j <br /> SIGNER Tm.E CEO DATE_ 12/09/11 <br /> - <br /> I <br /> I ITL <br /> Pair rh <br /> I <br /> I <br /> E <br /> #tt <br /> ON AL / <br /> DEPARTMENT USE ONLY r <br /> Application Accepted By Date 1-3 j>' Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit / <br /> Pump Inspection - Date �L /ta/ 0- WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS <br /> G- <br /> PE SC Recclved Cheeky Amount Date Permit Invoice# Well ID# <br /> Codes taro .B Remitted Servlre Rc uqt# <br /> 3�! 05o ZOl S3-� t Z 13 3; -D( d l 3 <br />