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#5455 WELL ! PUMP PERMIT <br /> FANNED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y I <br /> JOB ADDRESS 5184.W. Highway 12 CITY/ZIP Lodi 915242 y <br /> CROSS STREET I 5 APN 055-160-22 PARCEL SJ1. LAND USE APPLICATION# <br /> PHONE 368-7664 <br /> OWNER NAME <br /> QQQQ Frank C. Alegre <br /> OWNER AAKES9 W. Highway 12 CITY/STATE/Zip Lodi !CA 95242 '. <br /> CONTRACTOR <br /> Delta Stockton Pump PHONE 466-9625 <br /> CONTRACTOR ADDRESS <br /> 646 S. California Street CITV/SiATE/ZIP Stockton, CA 95203 <br /> PHONE <br /> SUBCONTRACTOR V <br /> CITYISTATEIZIP <br /> SUBCONTRACTOR ADDRESS <br /> Il <br /> LICENSE ',i ❑C-57 NC-61' ❑D-09 ❑Other NUMBER 724778 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section \ <br /> jINTENDED USE XJ Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: wet ystem Name ontacl Name or one Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> #of borings #of borings <br /> ❑Monitoring Well(s) #of wells ❑Soil Bodng(s) ❑Geotechnical <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of Service Well Renewal <br /> ❑New Pump Pump Replacement ❑Pump Repair ❑Cross-Connection Repair ' <br /> WELL CONSTRUCTION - . .. . <br /> Drilling Method ❑Mud Rotary Cl Air Rotary ❑Auger ❑Cable Tool O Push Point ❑Other. <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter l Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/GaugelASTM Sched ❑Steel 13Plastic ❑Stainless Steel C3 Other <br /> Grout Seal Depth ft ❑Neat Cement(941h hub/5-10gal water) ❑Sand Cement suck mix 7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids t % Name Q Specs on File- ❑Specs Submitted <br /> Grout Placement Metbod ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name)' <br /> PEDESTAL' Installed BY ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove,Pipe <br /> PUMP ElSubmersible ❑Turbine ❑Other HPPump Set b 3 ft Standing Water Level 20 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 /> WORKERS COMPENSATION LAWS. <br /> t I 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC'T'IONS <br /> SIGNED / TITLE CEO DATE 03/23/05 <br /> , <br /> MAN <br /> VA <br /> (� <br /> p: <br /> ,I. <br /> !, G <br /> P E � <br /> � E O <br /> ''D "P �y�'NyL`Y- --- <br /> Applica-tion Accepted ate Q 7-/d r Area Employee 1D# 3eo6 ��g <br /> Grout Inspec on Date ❑ SPECIAL Well Permit <br /> Pump Inspec 'on By --ir Dat a0�(� j- ❑ WAIVER Received <br /> i Destruction Inspection By -° Date Constructed Well Depth ft <br /> COMMENTS <br /> i <br /> PE SC ReceivedCheck# Amount Date Permit! Invoice# Well ID# <br /> Codes Info By --c—ash Remitted Service Request# <br /> i <br /> I� ' WELL PUMP PERMIT <br /> C:kiD 43.02•D06 - <br /> 9/6iO4 <br />