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17790 WELLIPUMP PERMIT <br /> SAN JOAQUIN COOlmYENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue•STOCKTON CA 952D5.6232-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> 0 <br /> Jos AODRaea 11 SS a r T I T Tr A.V33 CITy1ZJPSTICN QS2tS �$ <br /> CROSS STREET MAIN ST. APNI7.j- 19e17 PARCEL SO:E T�a„a LAND USE APPLICATION# A <br /> OWNERNAME ED PIAZZA PHONE 209 finR_RI'71 <br /> OWNER ADDRESS SAMF. CITYISTATE/ZIP <br /> CONTRACTOR Delta Pump PHONE 209-466-9625 <br /> CONTRACTORADoneas 646 S. California Street CITYISTATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTORADDRESS CITYISTATE21P <br /> LICENSE 00-57 9 C-61 D D-09 O other NUMBER. 724778 EXPmAT10H DATe 08/3 b <br /> GEOGRAPHICAL INFORMAmON: CoordinatesX Y Township_ Range_ Section_ <br /> INTENDED UBE g(giOmestic/Private O IRlgatlontAgdculunal D Industrial D Water Qua9ty,Monitoring 0 Sail Sampling/Characterl ation <br /> ❑POND Water System <br /> adRemM fmm Owner. ewe- Lon c ame or hono v <br /> TYPE OF WORK 0 New Well 0 Replacement Well ❑Well AlterallonlModlOcation 0 Other <br /> 0 Monitoring Well(s) #ofwelis 0 Soll Bodng(s) #Mlrod,pe O Geotechnical RA* T <br /> C <br /> 0 Out-OfService Well ❑Out-OfSeMce Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement APurnp Repair ❑Raise Well Casing J <br /> WELL CONSTRUCTION 0 <br /> Drilling Method 0 Mud Rotary 0 Air Rotary D Auger 0 Celle Tool 0 Push Point 0 Other �M o�ptgl <br /> Proposed Weil Depth ft Excavation In diameter D Open Bottom 0 Gravel PecldGravel Size rIn diameter <br /> 0 Conductor Casing In diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_In Thlckness/Oauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 to bag15.10 got Water) O Send Cement sack mfxR gal water <br /> 0 Bentun8e(20%solids) 0Other <br /> Grout Placement Method 0 Pumped 0 Free Fail 0 Other 0 Retardant/Accelerator(name) <br /> jEgU_"_Aj Installed By 0 Ddller 0 Pump Contractor ❑ Other <br /> O Concrote Pedeeta)Dlmensions:Width_ft Length ftThick In 0 Christy Box 0 Stove Pipe <br /> PUMP A@ubmersIblea Turbine 0 Other HP Pump Sat ft Standing Wstar Level R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> -- CURRENT AMD'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 /> DATE N/77�2nTS <br /> '""" 5. GILLIS AVE. <br /> ,1 <br /> � PUMP/WELL is localetl antler the bees <br /> y, ,; - + "�- apprOv,102 211L,Gom the curb or S.Gillis < l t� <br /> r�r22`` '110. <br /> •s ryf�''�` ��. .:���l !'�ax <br /> s <br /> l <br /> x <br /> Y <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Data ` e. Area �D u Employee IDA 322e <br /> Grout Inspection By 1 _ Dale SPECIAL Well Permit <br /> Pump Inspecllo68yA Date / 2� WAIVER Received <br /> Soil Boring lnspectlon By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Be Received Amount Date Perm"' Invoice# Well ID# <br /> Codas Info B Remitted Servlee Request# <br /> Yi 5 <br /> 7—:90517 <br /> EIal01Mesa'ar WELLrpUMP PEnMR <br />