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� Ica <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 <br /> PERMIT C'r]`. (209)953-7697 FOR INSPECTIOIw EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS P' UIX'r`�&h In /9L �el�r�, lkye� CITY/ZIP -770 Qm <br /> 2 <br /> D <br /> 42 <br /> 7 <br /> CROSS STREET /�L�l i 12 e- A.PIN J O�' 6 + PARCEL SIZE — / LAND USE APPLICATION X <br /> E}hwed ���sP ►n !�) y <br /> OWNER NAME PHONE�`�/�y�� <br /> OWNER ADDRESS �� &=2 - i CITY/STATE/UP—, 4JW r4?6Kr/. <br /> CONTRACTOR Delta Pufrip fnc'- PHONE (209 ) 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE ❑ C-57 CXC-61 ❑ D-09 ❑ Other NUMBER 1055434 EXPIRATION DATE 8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE XDomestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Ovmer: Water ystem Name contact Name or Phone Number-- <br /> TYPE <br /> um erTYPE OF WORK ❑ New Well ❑ Replacement Well Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) At of wells G Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> Out-Of-Service W II E Out-Of-Service Well Renewal ii Cross-Connection Repair <br /> New Pum um Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter C Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft C Neat Cement(94 Ib ba9/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length it Thick in ,j Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ 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 COM N ON LAWS. <br /> NIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE /O 17 / I <br /> j <br /> � f <br /> a <br /> AX. <br /> TMENT U E NLY <br /> Application Accepted By <br /> ZV-.--J Date P,rc,_��� Employee <br /> Grout Inspection By A I Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER.R <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received (CheSW Amount Date Permit/ Invoice#Iq Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> W P00 40 54- j <br /> s <br /> F `/O <br /> 8HD 43.05 - �j��QO�//� O, ELL RUMP PERMIT <br />