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WELL/PUMP PERMIT <br /> SAN JOACUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> p l�1Q1/n � <br /> JOB ADDRESS (`1 CITY/ZIP F/gy`n, L ("'arno '75- ,3 1 m <br /> \1' C o <br /> CROSS STREET vy M Q� P I F PN 113-13—C91 PARCEL SIZE • ✓ LAND USE APPLICATION# p <br /> L-.C)/\A (Dr-, cn <br /> m <br /> OWNER NAME Q Q ��rJ� ��^ r-) PHONE 510 - 9�`1- � z <br /> OWNER ADDRESS 1 U V �Je_ QG �VG. CITY/STATE/ZIP �iyc�^IY�re, CA 9.�a�3� <br /> CONTRACTOR Delta PumP-_qT12CxF,mnN ARMAT gR MOTOR WORKS SIE- 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 X C-61 ` D-09 D Other NUMBER 724778 ExPIRATIONDATE 081 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE A Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 <br /> E, Monitoring Well(s) #of wells ❑ Sail Boring(s) u of borings <br /> #of borings <br /> 7 R <br /> ❑ Geotechnical --pd V�� <br /> Out-Of-Service Well ❑ out-Of-Service Well Renewal ❑ Cross-Connection epair 7 �'' <br /> New Pump ❑ Pump Replacement X"Pump Repair ❑ Raise Well Casingv <br /> WELL CONSTRUCTION <br /> Drilling Method 7- Mud Rotary ❑ Air Rotary ❑ JAuger ❑ Cable Tool ❑ Push Point ❑ Other �k ?3 1n4„ <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/GA%ft' —in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft yEAEjE <br /> �*� ONMQpUN]Y <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Schad C Steel C Plastic ❑ Stainless Steel`T�Li NTA <br /> Grout Seal Depth ft C Neat Cement(94/b bag/5-10 gal water) C Sand Cement sack migFr al Water <br /> j :1 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ 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 Submersible❑ Turbine ❑ Other HP 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 /> rMINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED /✓'y TITLE CED DATE r7-5-1 <br /> 1 <br /> h <br /> - Vis]• r C►L <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date i=q� Area Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By EVqz�) LUOto C0uN\ Date �� 2�N WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43.06 <br /> 8/04/08 WELL/PUMP PERMIT <br />