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115833 WELL/ PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"a FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> 'l. <br /> H <br /> JOB ADDRESS 5302 E. Morse Road CITY/ZIP Lodi 95240 y <br /> ,/ O <br /> CROSSSTREET 99 Frontage APN 059-260-45 PARCEL SIZE 77'C� LAND USE APPLICATION# <br /> OWNER NAME .Tull Hortizuela PHONE 612-7417 <br /> OWNER ADDRESS 3521 Canyonland Road CITY/STATE/ZIP Stockton, CA 95209 <br /> CONTRACTOR Delta Stockton Pump PHONE 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS <br /> yy�� CITY/STATE/ZIP _ <br /> LICENSE Cl C-57 IYC-61 ❑D-09 ❑Other NUMBER 724778 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 16 Domestic/Private ❑Irrigation/Agncullural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterizanon <br /> ❑Public Water System <br /> If cI ferent fom netr , stet ystem ameContact ame or ane N..Ioll <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring WCII(s) #of wells ❑Soil Bonng(s) a of bonngs ❑Geotechnical a of bonnp <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump EXPump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in ThickncWGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb hag/3-/0 gal water) ❑Sand Cement .tack mix/7 gal water <br /> ❑Bentonite(209/6 solids) ❑Manufacturer Spec%solids % Name 0 Specs on File ❑Specs Submitted n <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other - <br /> ❑Concrete Pedestal Dimensions: Width It Length ft Thick in ❑Christy Box ❑Stove Pipe BY <br /> PUMP M Submersible ❑Turbine 0 Other HP 1 Pump Set 110 ft Standing Water Level 40 ft <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. V-t <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS r) <br /> SIGNED TITLE CEO DATE 07/27/05 1,1 <br /> l <br /> IV LIT <br /> O M NT <br /> Vil EA TH DTFW <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By .� Date ! C�$� Arm----- Employee ID# 53 417 <br /> Grout Inspection Date ❑ SPECIAL Well Permit <br /> Pump Inspecti n By Date/ ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth It <br /> COMMENTS - -- <br /> PE SC Received r ChecWAmount Date Permit/ Invoice Well ID# <br /> Codes Info B ash Remitted Service Request# <br />