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X08 _ <br /> WELL/PUMP PERMIT <br /> SAN IOAQUIN COUNTY EwRONmENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232 - (209)468-3420 <br /> NON-REFUNDABLE <br /> 2 PERMIT �l CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS a, 3) 0 0 N l 1 i r r u� 1 V C- crryroP_- L,6 f , / 0 <br /> CROs St RST 1E- ' Q r(1 P u _ N APN 0(o - I LI - 0)5 PARCEL SU5 r 6 9 LAM USE APPLICATION# Q A <br /> OWNER NAME ]/V 1 //��I I i CL ,-- M e� PHONE 2 09-339- .2-41I <br /> OWNER ADDRESS S A M ^ C1TY/STATEMP <br /> CONTRACTOR Delta PurmBq_T )rT<TON ARIVIATURF A MOTOR WORKS ffilii . 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITYISTATEILP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE21P <br /> LICENSE - O C-57 9 C-61 ❑ 0-09 ❑ Other NUMBER .724778 EXPIRATION DATE 08/jA <br /> GEOGRAPHICAL INFO)tMATION: COoldinates X Y Township Range Section <br /> ftfMNDED Use, 'X'Domestic/Private 0 Irrtgadon/Agricultural 0 industrial 0 Water Quality Monitoring O Soil Sampling/Characterization <br /> 0 Public Water System <br /> If diNarent horn Owner. water syswm Nam GonLftt Name or mono Num5w <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> O Monitoring Well(s) #of wells O Soil Boring(s) p of bodrw 0 Geotachnical i'ofbodVs <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair � 2 3 <br /> 0 New Pum ❑ Pum Replacement Pum Repair 0 Raise Well CasingSf1Ni 2019 <br /> WELL CONSTRUCTION <br /> C <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other N�CTj1�NMFoj NTq N� <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom p Gravel PacklGravei Size ti in YWibr <br /> O Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ In Thickness/Gauge/ASTM Schad O Steel O Plastic O Stainless Steel O Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bagt&10 gal water) 0 Sand Cement sack mix17 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall O Other O Retardant/Acceterator(name) <br /> PE ESTAL Installed By 0 Oder O Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width R Length ft Thick in 0 Christy Box O Stove Pipe <br /> PUMP ICSubmersibleO Turbine O Other HP Pump Set 12. to R 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.1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSI),MN LAWS <br /> MINI�l�"4-"&rR2 ADVANCE NOTICE REQUIRED FOR INSPECTIONS Q <br /> SIGNED TITLE CEO DATE <br /> ft <br /> • t x . <br /> AI <br /> Application Accepted By Date ✓ Area04 l Ernolov"ID# <br /> GroutInspection By Data SPECIAL WBII Pet mit <br /> Pump Inspection By �`�� Date jn4jU WAIVER Received <br /> Soil Boring Inspection By Date Constructed Wait Depth ft <br /> COMMENTS <br /> PE SC Received ee Amount Permw <br /> Codes Info 8 Remitted Date Service uest# Invoice# Well lD# <br /> F <br /> OP00 <br /> EMD 43-06 <br /> 8!04108 WELL/PUMP PERMIT <br />