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-�� 1 (0 <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLEPERMITCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS W , rm s4r K CITY21P Lodi/ i �v -'p'j I m <br /> Lou.) <br /> CROSS STREET Gr S 1700'0615e <br /> ac (3- D/ IqPARCEL SIZE 10d2 o � <br /> LAND USE APPLICATION if x <br /> OWNER NAME Te(]ar�J� ,'I`Q t-� PHONE �Q -/- 7 0 -—20, �J N <br /> OWNER ADDRESS S'29 -t CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump–_qTnC T<TnN ARMATURE R MOTOR WORKS ff"QIh. 209-466-962 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 0 C-57 aX C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/ta <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> JJ <br /> INTENDED USE 7(Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: a er ystem ame on ac ame or one um er <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other DA <br /> oS <br /> G Monitoring Well /l s) #of wells ❑ Soil Boring(s) f borings ❑ Geotechnical b: s <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair CE�VE <br /> 1:1 New Pump Pump Replacement. ❑ Pump Re air C Raise Well Casing <br /> WELL CONSTR,,TION 3 2nf. <br /> Y <br /> Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point 11 Other AAA <br /> (Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Siz1f1`� � <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft ""tPgRTM� <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic 0 Stainless Steel 0 Other N <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other iD Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller C Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> IPuMP g Submersible Turbine 0 Other HP 1� Pump Set ft Standing Water Level 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 /> a' MININ_W 24 HQJB ADVANCE NOTICE REQUIRED FOR INSPECTIONS j <br /> SIGNED TITLE CEO DATE -'/"-'+ <br /> �»..q.,T y *-P4W-0 --" <br /> V.' <br /> t . <br /> \ ' . <br /> " k ,A <br /> DEP..iLRTMENT USE ONLY <br /> Application Accepted By Date AreaEmployee ID#� <br /> Grout Inspection By Date ECTAL Well Permit <br /> Pump Inspection By Date Z WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS �� ` <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B a Remitted Date Service Re uest# Invoice# Weil ID# <br /> r—_ <br /> I A <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />