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0?w <br /> VVE LIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKT ON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMITCA.. (209)953-7`''37 FOR INSPECTIG,i EXPIRES 1 YEAR FROM DATE ISSUED <br /> - i��on q S (� 5 m <br /> Jos ADDress n 1" Q CITY/ZIP n' <br /> D <br /> c^� C 0 <br /> CROSS STREET { J Y-w J qe 11 PN 10-6, 3 , PARCEL SIZE Q �LA14D USE APPLICATION M <br /> OWNER NAME ( r(1 III r C^- N <br /> Q PHONE <br /> "1� � un'1 1 43373 �3owt'�gvE (� - /_ I <br /> OWNER ADDRESS I �i i CITY/STATE/ZIP!�i ���1(�l�) <br /> CONTRACTOR Delta Pump lI1C:- PHONE ( ,!09 ) 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-57 XC-G1 D-09 Other NUMBER 1055434 EXPIRATION DATE_B Ll 6/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domest,c/Private a I.rigation/Agricultural -- Industrial Water Quality Monitoring C Soil Sampling/Characterization <br /> .!'ublic Water System <br /> If different from Ovmer: 1wjazur ys;em Name Contact Name oronefi—I u�cr <br /> TyP OF Worn. ❑ New Well Replacement Well Well Alteration/Modification ❑ Other41 <br /> Monitoring Well(s) #of wells .= Soil Boring(s) of borings i-- Geotechnical <br /> enewal ❑ Cross-Conlr , n 0i <br /> 2 OU'-Of-Service Well Out-Of-Service Well Renewal Repair SA/y J <br /> ❑ New Pum ❑ Pum -Replacement Pum Repair ] Raise Well CasingF ✓Qq QUIAIr� <br /> WELL CONSTRUCTION �TH D�OAf /V <br /> Drilling Method -- Mud RotaIW, .n <br /> uger C Cable Tool ❑ Push Point ❑ Other RriwlENr <br /> Proposed Well Depthn in diameter L Open Bottom ❑ Gravel Pack/Gravel Siz diameter <br /> Conductor Cameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic Stainless Steel ❑ Other <br /> Grout Scat Depth ft 7 Neat Cement(94 Ib bag/5-10 gal Water) D Sand Cement sack mix/7 gal water <br /> 11 Bentonite(20%solids) E. Other <br /> Grout Placement Method J Pumped ; Free Fall C Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller '] Pump Contractor ❑ Other <br /> 7 Concrete Pedestal Dimensions:Width ft Length It Thick in Christy Box 7 Stove Pipe <br /> 40 PUMP Submersible: Turbine Other HP r Pump Set_ it Standing Water Lovel It <br /> 1 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS CONIUNIENSAZON LAWS. <br /> NV. ,i 24 Hi, C' p <br /> SIGNED 1I.E CEO - -- DATE j`1 J I I <br /> FIRP <br /> Oppr <br /> 19 <br /> _ D P AT M E NT U& O N L <br /> Application Accepted By `/ p�,e Ar•u �P' Employee ID;/�C�� <br /> Grout Inspection By Dale PECIAL Well Permit <br /> Pump Inspection By�- per, Date Z WAIVER Received <br /> Soil Boring Inspection By ' Date Constructed Well Depth it <br /> COMMENTS �/�—J f - � �J� �Aj <br /> PE SC Received Amount Permit/Codes Info B Cash Remitted Date Service Request <br /> # Invoice# Well ID# <br /> i <br /> EHD 43-06 <br /> 8/04108 <br /> WELL/PUMP PERMIT <br />