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qq I q� q <br /> WELL/PUMP PERMIT .: �1! �EU EU <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT /� ICALL 209 953-7697 FOR INSPECTIONS EXPIRES <br /> 1 YEAR FROM DATE ISSUED <br /> J08ADDRESS ��VI S. M,`Jb{e(+ R�7 CITY/ZtP_ �/� /�7ZJY� gs�l,S m <br /> (� 1 <br /> CROSS STREET 6Q�` Ip me d APN1or70 /-t)(.- 030 PARCEL SIZE 53.I q LAND USE APPLICATION# X <br /> rn <br /> OWNER NAME �h 11 a� e F rnn PHONE 209- Y 71-- 5 717 <br /> n a N <br /> OWNER ADDRESS~_ 4 I ��IlYIlrli Rd CITY/STATE/ZIP 54011K+bn 4Sa21 <br /> CONTRACTOR Delta Pump STOCKTON ARMATURE A MOTOR WORKS EAQ. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYIS7ATE/ZIP <br /> LICENSE . ❑ C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 0$/1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 0 Domestic/Private Xlrrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water ZSYStern Name ConlaCt Name or Hrione Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> G Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings SOAwlivu <br /> 0 Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair —REC6p <br /> ❑ New Pum 1 <br /> ❑ Pum Re lacement <Pum Repair ❑ Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other s20� <br /> Proposed Well Depth ft Excavation n diameter ❑ Open Bottom 0 Gravel PacWN I�{�� U <br /> GL © �r�fiameter <br /> Conductor Casing in diameter ! Conductor Casing Depth ft TH DEpA <br /> Well Casing Diameter_ in Thickness/GaugelASTM Schad 0 Steel 0 Plastic 0 Stainless Steel ❑ Other EFNT <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in D Christy Box 0 Stove Pipe <br /> PUMP G Submersible 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 /> ---^' NIIN1A+Ij ?4 FOU,ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO <br /> DATE <br /> .y <br /> 1 , ,* - <br /> J <br /> r_BEPARTMENT USE ONLY <br /> / <br /> Application Accepted By __ �/y Date Area Ile S <br /> Employee ID#_ <br /> Grout Inspection By Date I PECIAL Well Permit <br /> Pump Inspection By !`1ri6H'�� ` � -►e�h Date bl e'I l I`1 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 /> U �2- 22 1 y4POD3 '1 a <br /> EHO 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />