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#7215 WELL/PUMP PERMIT <br /> JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Avc 3—FL-SfOCiI CA 93292 -(309)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR ISSPF.CTIO\X EXPIRES I YEAR FROM DATE ISSUED y <br /> JOB ADDRESS <br /> 4580 W. Highway IP 12 Ci Lodi 95242 y <br /> b <br /> e <br /> Use A <br /> L31 Ntu LvY <br /> CROSS STREET <br /> N. Ray Road APN •PARCEL <br /> y <br /> OWNER NAME Don Phillifis PHONE 368-1687 <br /> OWNER ADDRESS SaID2 CIT\'/STATEIZIP <br /> CONTRACTOR Delta Pump __ PHONE 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CTTYISTATrJzIP Stockton CA 95203 <br /> PHONE <br /> SUBCONTRACTOR <br /> CrrYWATFJZIP <br /> SUBCONTRACTOR ADDRESS <br /> LICENSE O C-57 IXC-61 O D-09 ❑Other <br /> NUMBER 724778 ExwwsrwN DATE <br /> Y Township Ram Section_ <br /> CF.OGRAPHICAL INPORMATION: Ceordiaates X <br /> INTENDED USE ICI Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characten�auon <br /> 0 Public Water System oar y' arK onus.a o. a �m <br /> ud�tiarmriron �. <br /> TYPE OF WORK ❑New Well 0 Replacement Well 0 Well AlterntioniModification sof 6o Te Hole <br /> 0Other sof bonag — <br /> M of wells O Soil Boing(s) El Geotechnical <br /> O Monitoring )__ p instal <br /> ❑Well Destruction coon Renewal❑Oxct-Of-Service Well 0Oxct-0f-Service Well Pupt3IDll P <br /> 0 New Pump 0 Pump ReIiIacernent I OnnnpR it 0 Cross-Connection R air <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Toot 0 Push Point Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack I Gravel Sine in diameter <br /> in diameter I Conductor Casing Depth 11 <br /> - ❑Conductor Casing - <br /> 0 Steel 0 Plasnc 0 Stainless Steel O Other �� <br /> i Well Casing Diameter_in Thickness/GaugJASTM Schad 0 Sand Cement .ruck mix/7 gal water <br /> Grout Seal Depth fl 0 Neat Cement(94 1h bag 15-10 got1 wurrr) j <br /> 0 Bentonite(20%solids) O Manufacturer Spa'!.solids__ <br /> 9' Name 0 Specs oo File 0 Specs Submitted <br /> Grout Placement Meshed ❑Pumped <br /> O Fres Fall 0 Other 0 RctaDiant I Accelerawr(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other — <br /> 0 Concrete Pedestal Dimensions: Width_ R Length_ft Thick m 0 Christy Bos E3 Steve Pipe <br /> _ HP 1 Pump Set $4 ft Standing Water Level 22 R <br /> PUMP M Submersible 0 Turbine 0 Other _ <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 G <br /> WORKERS COMPENSATION LAWS. <br /> IMLM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 07/18/06 _ <br /> -TITLE CEO DATE _ <br /> SIGNED � a��� <br /> i <br /> 1 <br /> N t' kM <br /> DEP RTMENT USE PNFY <br /> Application Accepted By <br /> Date ` Area. -- Employee IDM <br /> '���. / Date —_-- 0 SPECIAL Well Permit <br /> Grout Inspection BRAi"! f� <br /> Date /�//�/l� 0 WAIVER Received <br /> Pump Inspection iw <br /> Date <br /> Well Depth— Q <br /> Destruction Inspection By <br /> COMMENTS <br /> _ PE SC Received Check#1 Amount Permit/ Invoice$0 Well IDM <br /> Codes Info Cub Remitted <br /> Date Service R uesl M <br /> n-.7 <br /> WELL PUMP PERS <br /> ERD 47.02-W <br /> a/N00 <br />