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00 <br /> VELLIPUMP PERMPT <br /> SAN JOAQUC!COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT -' '.'- 209 953-7697 FOR INSPECTICo- EXPIRES 1 YEAR FROM DATE ISSUED <br /> Job ADDRESS � g a 5 N -4wi -� 5 -� �5�,a m <br /> CITY/ZIP � Lnm <br /> D <br /> p Q 0 <br /> CROSS STREET i6rLtryLb,4 APN 0 0 I'Q - PARCEL SIZE&.1(fLAND USE A//P��PLICATII�O,N{NIr p m <br /> Soh m./C PHONE dloq Fg�j o �-3 �n <br /> OWNER NAME rQC/SPA_ I <br /> OWNER ADDRESS _ ISA/q I- CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump Ti1c PHONE ( t)9 ) 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 AC-6'i D-09 -, Other NUMBER 1055434 EXPIRATION DATE 8/16/2 0 <br /> GE=OGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE a Domestic/Private L•rigation/Agricultural Industrial ❑ Water Quality Monitoring -: Soil Sampling/Characterization <br /> - Public Water System <br /> If different from Owner: Vater ystem Name Goniact-N-a-m-F-o-rPhone Numuer <br /> i <br /> TYPE OF WORK :1 New Well Replacement Well :1 Well Alteration/Modificatian Ll Other <br /> Monitoring Well(s) #of wells -- Soil Boring(s) °i borings - Geotechnical of 5°rings <br /> Out-Of-Service Well = Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump P(Pump Replacement - Pump Repair Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary -Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point C Other <br /> Proposed Well Depth It 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 :jPlastic ❑ Stainless Steel C Other <br /> Grout Seat Depth ft C Neat Cement(94 Ib bag/5-10 gal water) !7 Sand Cement sack rnix17 gal water <br /> Ci Bentonite(20%solids) E Other <br /> Grout Placement Method ❑ Pumped , Free Fall Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller 7 Pump Contractor L Other <br /> Concrete Pedestal Dimensions:Width ft Length it Thick in Christy Box Stove Pipe <br /> PUMP . Submersible:7 Turbine : Other HP Pump Set ft Standing Water l cvel tf <br /> c <br /> I HEREBY CERTIFY THAT I HAVE PRE=PARED 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COM N -ON LAWS. <br /> 24 HOUR ADVANCE NOTICE ICE REQUIRED FOR INSPECTION: <br /> o ag-1� <br /> SIGNED � _ TITLE_CEO DATE <br /> j V1 <br /> ffi& <br /> North of Brumby,aster ' _ * w~ a . <br /> ;6. of driveway. <br /> , '' . ,•�'�`; �,, X16 ��, l 'bIi <br /> ur <br /> J it i'�}' <br /> • 1�4 ,fir �f �o ''8 t 1, '+ 7.,)1 <br /> nt ?. f i <br /> .w. <br /> . <br /> D A R M E N T U S E O N L Y <br /> Application Accepted By T�f <� Date Area Employee ID,: <br /> Grout Inspection By Data SPECIAL Well Permit <br /> Pump Inspection By vACILrr, Date l��1p �� WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#! Amount Date Permit/ Invoice �r eli ID# <br /> Codes Info B C Remitted Service Request# 0 <br /> WPOO40a55 '`�✓ a i <br /> �O,q <br /> EHID PERMIT <br /> ,\ E9LT O�IM OUN <br /> 8704108�6 MT <br /> j��.fLT/PUMP <br />