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115299 WELL/PUMP PERMIT �'^ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JW E WEBER AVES�.a AMM02 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 1209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> N <br /> JOSADDRESS 7514 F T lint Fwad cffvmP Stockton 95205 <br /> 6. 0 <br /> CROSS STREET Mariposa APN 173-040-40 PARCEL SIZE t�41 LAND USE APPLICATION p <br /> OVMER NAME Rosario Costilla PHONE 547-8987 lR? <br /> OWNERADDRESS 6dm2 CIT'/STATE/ZIP <br /> 6. CoNTRAnost Delta Stockton Pump PHONE 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATFIZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> ` SUBCONTRACIORADDRESS CrTV/STATEIZIP <br /> LICENSE 0C-57 rxC-61 13 D-09 ❑Other NUMBER 724778 EXPIRATION DATE <br /> GEOGRAPINCALINFORMATION: Coardinntes X Y Township_ Range_ Section <br /> 6. INTENDED USE M Domestic/Private ❑Irrigation/Agdcultuml ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chalacteneation <br /> ❑Public Water System <br /> Hd Hr tm,mO— WamrSysmaiNam onucr ame or e u r <br /> TYPEOFWORK C3 N.Well ❑Replacement Well D Well AltentioNModifiration ❑Tat Hole ❑Other <br /> 6 ❑Monitoring Well(s) of wells ❑Soil Bonng(s) n°TbodmN ❑Geotechnical sofwr., <br /> ❑Wall Destruction ❑Out-0f-Service Well ❑Out-Of--Smite Well Renewal <br /> ❑New Purnp, NPurne R iacement ❑Pump Repair ❑C.-Connection Repair <br /> WELL CONSTRUCTION <br /> ` Drilling Method ❑Mud Rotary ❑Air Rotary ❑Angst O Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Six in diameter <br /> ❑Conductor Casing indiarrleter / Conductor Casing Depth ft <br /> Well Casing Diameter_in ThicknessrGauge'ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Me, <br /> Grout Said Depth ft D Nest Cement(94/h hag/5-/0 gal Weaer) ❑Sand Cement sack ma/7 gal Water <br /> lins, ❑Bentonite(20% [ids) ❑Manufacturer Spec%solids_% Name - ❑Specs on File ❑Specs Submifted <br /> Grout Pincement Method ❑Pumped ❑Fmc Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 13 Drilla ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ R Length ft Thick in ❑Ch lay eon ❑Stove Pipe m <br /> Raw1010 Submersible ❑Turbine ❑Other HP 1 Pump Set 105 R Standing Water Level 65 ft <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. 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 /> L WORKERS COMPENSATION LAWS. r <br /> MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 01/21/05 !^y` <br /> `V <br /> U <br /> L <br /> L <br /> P <br /> L ° <br /> tetALI <br /> - t <br /> �. <br /> DEPARTMENT USE ONLY <br /> Y. / [ A <br /> Application Accepted By— �O� Dale 2 2 tOS Area �10 Stop mlD# S$1k[L/ (C <br /> Gmut Inspection By Date ❑ SPECIAL Well Permit / <br /> Pump Inspection Date zA;/7T ❑ WAIVER Received <br /> ion Destruction Inspection By Dam Constructed Well Oepth R <br /> COMMENTStl7 <br /> L PE SC Received Checklist Amun <br /> ot Permitl <br /> Codes Info B Cash emitted Da[e Serving uest# Invoice# We111Op <br /> 43.&1 oso II s0.00 p 5 i7 1355 <br /> L <br /> E1113434YWfi WELL PUMP PERMIT <br /> N6J1 <br />