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20948 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN 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 /> JOB ADDRESS 12751 Thornton Rd. CITY/ZIP Lodi 95242 m <br /> (� D <br /> CROSS STREET H W Y 12 APN 055-13-01 6 PARCEL SIZE 1 6 0 . `LAND USE APPLICATION# <br /> OWNER NAME City of LOCA cn <br /> PHONE 209-625-6933 rn <br /> OWNER ADDRESS Same CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump—STOCKTn T ARMATURE & MO'T'OR WORKS ff"&h. 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 ❑ C-57 X C-61 D-09 a Other NUMBER 724778 ExPIRATIONDATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 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 '-1 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) rings <br /> s #of borings #afboriy� <br /> ❑ Geotechnical <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> New Pump 0 Pump Replacement J<Pump Repair ❑ Raise Well Casing > •a , <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other E �O�Q 2018 <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> j <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic Fj Stainless Steel ❑ Other FNT <br /> Grout Seal Depth ft ❑ Neat Cement(94/b bag/5.10 gal water) Ll Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall ❑ Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe <br /> PUMP ❑ SubmersibleR Turbine 0 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 /> MJNIM�V. 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED y TITLE CEO12 1 1 /18 <br /> ... _ rlerc <br /> it"en <br /> 4 4 <br /> Aprox 260 <br /> ft from 1-5 '� <br /> ARM-mil W­ <br /> Aft <br /> 1- 7 <br /> Application Accepted By Date Area LOCI Employee ID#Z� <br /> Grout Inspection By Date ISPECIAL Wen Permit <br /> Pump Inspection By��Y>itr 11 W �hevvxn Date k j I j WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTSV <br /> PE I SC Received Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />