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16526 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 /> En <br /> JOBADDRESSN Ham T anc CITY/zIpLodi 95242 i m <br /> g <br /> CROSS STREET _APN 059-08-007 PARCEL SIZE 10 LAND USE APPLICATION# I m <br /> N <br /> OWNER NAME 1--ra 1 QQ Thompson PHONE 209-369-4838 u <br /> OWNER ADDRESS 1 1 Q 1 3 N Ham T.a n g CITY/STATE/ZIPT ndi rA 95242 <br /> CONTRACTOR Delta Pump PHONE 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 D-09 0 Other NUMBER 724778 EXPIRATION DATE 0814 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> I INTENDED USE X0 Domestic/Private ❑ Irrigation/Agricuitural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If dMerent from Owner water5yaterh Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well ❑ Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 0 Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement X Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> !Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth It Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravol Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thlckness/Gauge/ASTM Sched 0 Steel 0 Plastic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack m&17 gal water <br /> ❑ Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other it Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller 0 Pump Contractor 0 Other_ <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe I <br /> r— <br /> PUt.7P lSubmersible❑ Turbine 0 Other HP „ra Pump Set--j-2Z—ft Standing Water Level <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 /> MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 7-3-2014 <br /> ORM <br /> � S <br /> _ 9 <br /> i <br /> lVNT <br /> FD <br /> ?014 <br /> -- <br /> Q,/IV <br /> CO(JE Ell I 1 11 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> TAINTl' <br /> rMENT <br /> I DEPARTMENT USE ONLY <br /> Application Accepted By M/? Date -7410101 Area VV Ct I ?C/ Employee ID# <br /> Groutinspects Date SPECIAL Well Permit <br /> Pump Inspection Date WAIVER Received <br /> Soil Boring Inspects n B Date Constructod Woll Depth It <br /> COMMENTS ' - TZ' C <br /> lek- <br /> PE SC i Received I Chec Amount PermiU <br /> Codes Info B s Remitted Date Service Request# Invoice# Well ID# <br /> (f-3S 05b oZ 375 7 IS 3 00?402- <br /> --HD 4306 WELL/PUMP PERMIT <br /> 8103,,08 <br />