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, <br /> WELL/PUIVIP PERMIT JF <br /> `1I70 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CA'.' "nn,' 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> J06 ADDRESS 950 L T CITY/ZIP MaAe,C�2 g 533 �Q m <br /> D <br /> CROSS STREETco-S 1Pi 1 ���!( BOJ`f/�D PARCEL SIz9' q7 LAND USE APPLICATION 1 <br /> pp� Qp c y En <br /> m <br /> OWNER NAME n _1 ,y,� / PHONE 20 /O 7 3 ' / y <br /> OWNERADDRESS (4 -5 -S (�� t✓1V CITY/STATE/ZIP E sea/on 953x0 <br /> CONTRACTOR Delta PlifnIp ffj(i _ PHONE ( 2o9 ) 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57C-i"i D-09 Other NUMBER 10 5 5 4 3 4 EXPIRATION DATE_ 8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ?Q7omestic/Private C Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring :; Soil Sampling/Characterization <br /> . Public Water System <br /> If different from Owner: water System Name Contact Name or Phone Numuer <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification U Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) u of borings Geotechnical a of boring <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pum i Pump Replacement :*Lmp Reoair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ; Air Rotary ❑ Auger Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic G Stainless Steel -. Other <br /> Grout Seal Depth ft C Neat Cement(94 Ib bag/5-10 gal water) Ci Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method -1 Pumped ❑ Free Fall C Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ] Christy Box 7. Stove Pipe <br /> PUMP Submersible Turbine -: Other HP Pump Set ft Standing Water Level It <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNT`( 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 C0P,9 N 01 LAWS. <br /> 6� <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS I q <br /> SIGNED TITLE CEO DATE <br /> 71C <br /> M, ♦YR fi !�y�4+1a <br /> est • '"rrJ3 <br /> _ rha � <br /> '� sY <br /> �w# rk• K <br /> z� � r <br /> 4 w x e g r '.� <br /> ' z�^� <br /> rpy tTg'',,��e <br /> WIN <br /> D,EPPIRTMENT USE O <br /> Application Accepted By r Date Area__ Employee ID; <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Y Y t�.r r Date I I� G WAIVER Rett ed <br /> Soil Boring Inspection By Date Constructed Well D "d ft <br /> COMMENTS <br /> -- r <br /> PE SC Received heck#/ Amount Permit/ <br /> Date ce# q Well ID# <br /> Codes Info B Cas Remitted Service Roque <br /> St// <br /> WP0040a53 Ttio ",v <br /> RT q� <br /> 31 <br /> EHD d3-Do <br /> BIO4108 WELL/PUMP PERMIT <br />