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#9193 WELL/PUMP PERMIT <br /> S.qN JOAQL7N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E.Main Street-STOCWMN CA 95202 -(209)468,3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 5302 E. Morse Road CITYPLIP Lodi 95240 + / <br /> CROSS STREET 99 Frontage APN 059-260-45 PARCELS.14"'0[ LANDUsE APPUCAMN 0 <br /> OWNER NAME Servillano Hortizula PHONE 612-7417 •, <br /> OWNER ADDRESS 5000 Tudor Rose Glen C-nT/sTATE/ZIP Stocktou, CA 95240 <br /> CONTRACTOR Delta Pump Piton 209-466-9625 <br /> CONTRACfORADDREsi 646 S. California Street Crrr/sTA'tLaw Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS_ CITY/STATE/ZIP <br /> LICENSE 0 C-57 XYC-61 ❑D-09 DOther NUMBER 7 24 7 8 ErtPIRATIUN DATE 8/08 <br /> GEOGRAPHICALINFORMA77ON: Cnordlnates X Y Township Rangt Section N <br /> INTENDED 1sF. b5nmesticiPi,,ate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactimization <br /> L ❑Public Water System If different from Owner attr y're. .me Coaw Nwe a e Numb. I 1 <br /> TYPE OF WORK O New Welt ❑Repla:,ement Well ❑Well Alteration/Modification ❑Other 1 <br /> ❑Monitoring Wtll(s) #of wells ❑Soil Boring(s) a of borings G Geotechnical N of borings <br /> ❑Ont-Of--Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> 13 New PunV 0 Pump Re ivyIrmat MmpRepair Raise pump, repair broken wire o <br /> W ELI,QNM(ICTION �— I�'�_t <br /> Drilling Merbod ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool O Push Point ❑Other M <br /> Proposed Weil Depth fl Excavation, in diameter D Open Bottom ❑Gravel Pack/Gravel Sae in diameter t <br /> ❑Conductor Casing in diameter / Conductor Casing Depth it <br /> Welt Casing Diameter in Thickness/GauWAST&I Sched ❑Steel ❑Plostic (3 Stainless Stool D other <br /> Grout Seal Depth 11 ❑Nat Comm(i4 lb bog/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Sper,^/o solids % Nam_ ❑Specs on File O Specs Submitted <br /> Grout Placement Metbod ❑Pumped ❑Frec Fall ❑Other_ 13 Retardant/Accelerator(name) <br /> EED SIAL Installed By ❑Driller ❑Pump Contractor ❑ Other i <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in D Christy Box ❑Stove Pipe <br /> PUMP E Submersible ❑Turbine ❑Other HP_�_Furap Set 110 ft Standing Water Level 40 It <br /> I HEREBY CERTIFY THAT I 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 CALIFORNLA CONTRACTORS STATE.LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 1141N1 N124 HOUR ADVANCE NOTICL REQUIRED FOR INSPECTIONS i <br /> SIGNED TITLE CEO DATE 12/07/07 <br /> I <br /> Vj <br /> d <br /> N <br /> n I : <br /> L <br /> r s � <br /> 1 L <br /> 7 <br /> F <br /> {/� EPARTMELYT U E NLY <br /> Application Accepted Res ` Date Area Employee IDN <br /> Grout Inspection By Date 13 SPECIAL Well Permit JJ <br /> Pump Inspection t ~, - -" r- Detc ///��C�cr'� O WAIVER Received <br /> Constructed Well Depth fI <br /> COMWNTs <br /> PE SC Received ec Amount Per <br /> Date <br /> Codes Info B ash Remitted ry ce He ues Invoke# Welt Eft <br /> o5V # of 2,71 ' <br />