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WELL/PUMP PERMIT <br /> SAN JOAQ➢ CODnry ENyptoNa6N RT asn DEPARTMENT 1314408 600E-Main Strat-STOCRTON CA 95202 . (209)468-7420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 I.OR INSPECTIONS EMPIRES I YEAR FROM DATE ISSUED <br /> L <br /> JOB ADDRESS 14629 Wildwood Road Cml-LIP Stockton 95215 <br /> CROss STREET Jack Tone ,AEN 203-030-02 PAacn.sae ��-� LAND VsgwreurAnonF <br /> II <br /> Ow RNAML Marilyn Stanley PRONE 579-5661 <br /> OWNER ADDRESS 1910 Black Slate Court Crn/SrnTa,7" Cold River. CA 95670 <br /> Cor T scsoa Delta Pump Palo E 209-466-9625 <br /> COMRACTORADDRESs 646 S. California Street Cm/SrATEIZIP Stockton. CA 95203 <br /> StIBCONTRAcrOR PHONE <br /> SUBCOM elrOR ADDRESS Crr1'/STATTJZR <br /> UCLN$L 0C-37 ]QCfii 0D09 17other NDMBPJr 724778 EE TIONDATE 08/12 <br /> GeaeRAPerw.InroRMAnon: C"OrdinatU X Y Township_ Range_ Section_ <br /> INTENDEDUSE )VIDorustiWrivele O lrrigati"NABriculesal 13IdmDsl ❑Wamr Quality Monitoring Cl Soil Sampling/Chaheetcri>yion <br /> ❑PublicWetermem <br /> S <br /> Iraamm aam W. n"m N. .1 .mew c <br /> TITLOFWORR 13 New Well O Replacement Well ❑Well Alkntio./Modifiication ❑Otho <br /> O Monitoring Well(,) oof wells ❑Soil Boring(I) "banap ❑Gatechnieel s°fbmwgs <br /> O 0.1-Of-Saw"Well OOutAf-Seevke Well Renewal ❑Crow-Cowation Repair j <br /> O New Pump M Purnp Replacement O purrip Repair <br /> WELL CON57RUMON <br /> Drilling Metbod ❑Mud Rotary O A4 Rotary O Auger Q Cable Tool O Push Point Cl GRmr <br /> Proposed Well Depth R Ekuvtion wdimaler ❑Open Been. ❑Gravel Fak/Gravel Size in distrue I <br /> ❑Conductor Cuing iodiurater / Conductor Cuing Depth R <br /> Well Casing Diameter w Thkk easlGaugVASTM Sdmd O Steel O Pittk O Stainless,Steel ❑Other <br /> Groat Seat Depth R O Net Cement(Y4 to bag/3-10gal waur) O Send Cement .rack mis 17 pi water <br /> 0&ntonim(20 solids) OManufaemmr Spec%solids_% Name OSpeesoo File ❑Spec Submitted I <br /> Groat Pluement Method OPumped ❑Fra FW ❑Other 0Retardant/Accelerator(neme) <br /> p,EDssTAL Installed By C3 Miller ❑Pump Contnesor O Other <br /> O Concrete Pedutal Dimensions:Width 0 Lm RThick in ❑Chrwly Be. ❑Stove Pipe <br /> Elm )IXSubmenbie ❑Turbine OOtba HP Pump Sa 115 ft Suandinj Wates Level 7 a <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL.BE DONE W 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TrtLL CEO DATE 07/06/12 <br /> N <br /> 0;0,1N ;OUNTY <br /> E D P T E T <br /> DEPARTMENT <br /> UI$,E, IQNLY _ �i <br /> Application AcceptedB DateLl (7 Area Employeel)a <br /> Grout Impezuou By Date , r ❑ PCCUL Wen Permit �1 <br /> Pmnp Inspection Dete Z� ❑ WAIVER Received <br /> Coa,trucmd Well Dtftb R <br /> COMMENTST�!za� � e5d s <br /> PE Sc Received Case Awe"at Date Perm1U Invoice Well/oo <br /> Codes Info B h RtmlNed Service Re aestg <br /> 7pyo Gc 3 z. S2cD bs 1 <br />