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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 INSPECTION:: EXPIRES 'I YEAR FROM DATE ISSUED <br /> �J ' f J /� ( Ln <br /> JOB ADDRESS � ) 5o VvG7l(U rngn rt V e. CITY/ZIP S+mk f-6rt q5 a 0 % m <br /> CROSS STREET Thorn+on HPIS V 0 D O D 6 PARCEL SIZE Y• 3 I LAND USE APPLICATION <br /> r N <br /> OWNER NAME C /�A"� 1� c.,,bclker /P�HO�N�E-��f,��9-4�a�_/��3/�5 <br /> OWNER ADDRESS S/-y r V C_ Rl15, rr CITY/STATE/ZIP <br /> CONTRACTOR Delta Purnp lnc- PHONE ( t)y ) 466_9625 <br /> CONTRACTOR ADDRESS 646 S. California St CITYiSTATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE G C-57C-Gi D-09 ❑ Other NUMBER 105543 4 EXPIRATION DATE_8/1 6/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial D Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner: WaLerSystem Name contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings , Geotechnical <br /> ❑ Out-Of-Service Well C Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> Nov 1 <br /> New Pum Pum Replacement _ Pum Repair ❑ Raise Well Casing �Y <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary C Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other SqIV <br /> lit NVIAQU/N COU <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PacldGravel Size Q/ALTH OF � <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel D Plastic ❑ Stainless Steel G Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) L"1 Sand Cement sack mix17 gal water <br /> tl Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall C Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller '_1 Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible❑ Turbine Other HP Pump Set fl 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 COMVjENUjjON LAWS. <br /> V1 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED =�F TITLE CEO DATE <br /> Pump is in small shed r <br /> ► *- southwest of pool <br /> ` T <br /> ' &P <br /> r' <br /> D PA TMENT USE ONLY <br /> Application Accepted By Date f! Area Employee IDf# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By DateII �q WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth r'A eft <br /> f 1 <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 <br /> 8104108 WELL/PUMP PERMIT <br />