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L t ++ <br /> 18997 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazolton 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 3732 E CARPFNTFR Rn- CITY/ZIP STOCKTON 95215 env <br /> j CROSS STREET Hwy q9 APN 179-16-050 PARCEL SIZE��LANO USEAPPLIGATION# 1§ <br /> A s;b -i 1 rir_ ' m <br /> OWNERNAMEWAT DHAMMARARAM BUDHIST TEiziiTi Pao. 209 943-2883 <br /> OWNERADDRESS SAME CITY/STATEIZIP ` <br /> CONTRACTOR Delta Pump—STQCKTriN ARMATURE & MOTOR WORKS MO. 209-466-9625 � <br /> CONTRACTORACDRESs 646 S. California Street CITYISTATEJZIP Stockton CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Cm'/STATEIZIP <br /> 'LICENSE D C-57 X C-61 D D-09 ❑Other NUMBER 724778 EXPIRATION DATE 08/11 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE D DomesticlPrivate RXrigationlAgnculturai 0 Industrial 0 Water Quality Monitoring O Soil Sampling/Characterization <br /> O Public Water System i <br /> If tWeImt horn Owner e ryy <br /> ys m atrre on ams a e Number <br /> l" <br /> TYPE OF WORK D New Well 0 Replacement Wel! 0 Well Alteration/Modification 0 Other ka <br /> ❑Monitoring Wells) #of wells 0 Soil Borings) 9 of 6or-9- ❑Geotechnical <br /> 0 Out-Of-Service Well 0 Cut-Of-Service Weil Renewal O Cross-Connection Repair NO 3 <br /> 0 New Pump O Pump Replacement V,,FumpRepair 0 Raise Well Casing SA 0 2 <br /> WELL CONSTRUCTION FN(/ Otll <br /> Drilling Method 0 Mud Rotary O Air Rotary 0 Auger D Cable Tool 0 Push Point ❑ Other N �L7 f�OhL ! U <br /> Proposed Well Depth ft Excavation In diameter 0 Open Sodom ❑Gravel PackJGravel Size In�e7ytq <br /> O Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Dlameter_in ThlcknessJGauga/ASTM Sched 0 Steel O Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bag15-10 gat water) O Sand Cement sack mix17 gal water <br /> i7 Bentonite(20%solids) 0 Other <br /> Grout Placement Method O Pumped O Free Fail 0 Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By O Driller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP iii Submersible4{XUrbine O Other HP_J_5_ Pump Set I ft Stanoin9 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. t ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT.1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSAT N, <br /> 91 MINIMUPA 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE <br /> PUMP/W EU.IS Located ac the west..I point en tM <br /> _�I R �: ProprrtY rMdr the rolA.Se@IM1fCII <br /> DEPARTMENT SE ONLY <br /> ,(�y, ) r <br /> Application Acueptad By' Date '+7 Area.jEmployee ID# 13 1 <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE9C Received eck#1` Amount Date Permit( Invoice# Well ID# <br /> Codes Info B I Remitted Service Re uest# <br /> I i <br /> EHD 43-0a WELL!PUMP PERMrr <br /> erXoa <br />