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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNIN ENVIRONMENTAL HV 3EPARTMENT #10938 600 E.Mein Street•Si. N CA 95202 •(209)468-3420 <br /> NON-REFUNDABLE PERMIT ' l CALL 209 953-7697 FOR INSPECT IONS EXPLR S I YEAR FROM DATE MUED <br /> JOBADDRE 4350 Newton Road <br /> arrrzrp Stockton 95205 <br /> CROSS STREET Wilson Way. APpt_ 132,040-03 ,_yARCEL5IZE Sit—L.-USE APRUCATTON9 <br /> OWNERNAME Danny Rackley PRpmE 948-8586 <br /> O%YNERADDRESS P.O. Box 5706 CITYISTATEr2rP _Stockton, CA 95205 ^� <br /> CONTRACTOR Delta Pump mm� PnoNE 209-466-9625 —.,-� <br /> CONTRACTOR.A DURESS 646 S. California Street C.1Tv1STATVZlr' Stockton. CA 95203 <br /> SUBCONTRACTOR PHONE a <br /> SU$CONTRACTOR ADDRESS CITYISTATFJZIP <br /> j LICENSE 0 C-57 XXC-61 O D-09 0 Other NUMSER 7 247 78 EXARATION DATE 08/10 <br /> I <br /> GEOORAPRICAL INFORMA'GON; Coordinates X <br /> Y Tonoship Raape Section <br /> .Itri 2M D Use Mlotnesticlprivate O InigatiordAgricultural (3ladustrial O Water Quality Monitoring C Soil SamplingrCharactcrizstion i <br /> ❑Pub]ic Watcrsyystem <br /> 111 7ldiffe�i from OwrKr: %t ys-em ams Cautivi eme sn Phout N.Mbc. <br /> TYPE 01 WORK 0 New Weil O Replacement Well Cl Well AlteratioroModifrcation 17 Other <br /> 0Monitoring Welt(s) #orwelis CScitBorin s Marbai. ealboriags <br /> Boring(s) ps C Geotechnical <br /> O Out-Of-Service Well C Out-Of-Service Well Renewal Q Cross-Connection Repair <br /> C New Pum _XXEaLni2 Replacement O Pump,Reparir <br />{ <br /> WELL CON5771sx-nna <br />` Drilling Method O Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool C3 Push Point a Other <br /> Proposed Well Depth ft Excavation in diameter O Open bottom C3(Iravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter_in ThicknesslGaugeIASTM Schad CI Stael ❑P]astic O Stainless Steel 0 Other <br /> Groul Seal Depth R O Neal Cement(941b bag/S-IO gal water) 17 Send Cement jack max 17 gal water <br /> 13 Bentonite(20%so]ids) 0 Manufacturer Spec%solids_% Name O Specs on Filo R Specs Submitted <br /> Grout Plectmeot Method C Pumped 0 Free Fall 0 Other C Ruerdent/Accelerator(name) i <br />� FhMMTAL lesulltd By O Driller ❑Pump Contractor p Other <br /> (3 Concrete Pedestal Dimecsines:Width 11 Length B Thick in M Christy Box 0 Stove Pipe <br /> PI EIC $}5ubrmrsibIc ❑Turbine OOthcr HP 2 Pu mp Set_jQ_7 ft Standing Water Leval 70 ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUUMD LICENSE i3 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS_COMPENSATION LAWS, <br /> IMUM 74 HOUR ADVANCE NOTICE REQUIRED FOR INSPFC•FIONS - <br /> SIGNED TTTix CEO DATg 05/14/09 <br /> I <br /> T <br /> D <br /> F <br /> r <br /> —DE P R T M E N T USE O L Y <br /> Application AcceptedDate <br /> Area Employee 1D# <br /> Grow insptUion By pate ❑ SPECIAL Well Permit / <br /> Pump Inspection By 04Arh _ Date 10' WAIVER Received ✓✓✓ <br /> Coaatrurted Well Depth ft <br /> COMWNTS <br /> PE SC Received Amount Date PermiU Invoice# well UM <br /> Codes lolo By. Cash Remitted Service Re ueItb <br /> 0 .7 <br />