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433 <br /> WELL/PUMP PE RNH u <br /> SAN.JOAQUIN COUNTY ENVIRONMEN-CAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT _ CA!. '..(209)953-7697 FOR INSPECTIONS EXPIRES "I YEAR FROM DATE ISSUED <br /> of Pt- S?ri essl- 12 French OQmp gJ'a31 m <br /> J06 ADDRESS . CITY/ZIP I D <br /> 0 <br /> CROSS STREET_ 'K tr °tom I Ln HPI,,_1 y'3' q- 030 PARCEL SIZE- , as LAtQD USE APPLICATION,•- M <br /> OWNER NAME Ear leen <br /> l�a mhers PHONE Q g" �Q (1Q `-' 54e N <br /> OWNER ADDRESS 5a' -` G CITY/STATE/ZIP <br /> CONTRACTOR Delta Plitfip Tf1C'- PHONE ( 109 466_96 2-9 <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 EXC-GI D-09 Other NUMBER 10 5 5 4 3 4 EXPIRATION DATE 8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township RangC Section <br /> INTENDED USE XDomeslic/Private ❑ Irrigation/Agricultural ❑ Industrial :. Water Quality Monitoring - Soil Sampling/Characterization <br /> Public Water System <br /> If difforont from Ovmer, Water System Name COn;act Name or Phone Numner <br /> TYP=OF WORT: ❑ New Well ^ Replacement Well ❑ Well Alteration/Modification ❑ Other NA. �— <br /> Monitoring Well(s) #of wells Z Soil Boring(s) #of borings Geotechnical--� ,., / N I <br /> T <br /> -1 Out-Of-Service Well -- 1.Out-Of-Service Well Renewal ❑ Cross-Connection Repair jFl � <br /> - New Pum E Pum Replacement um Repair L-1RaiseWell CasingVCD <br /> WELL CONSTRUCTION 0 5 2010 <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter Li Open Bottom ❑ Gravel Pack/Gth ft r��f$t�q QV�prj8)�f-eter <br /> Fj <br /> Well Casing Diameductor CanngThickness/Gauge/ASTM Scl ed ductor Casing Do7pSteel ❑ Plastic ❑ Stainless StezALr O�EPq lMFNT <br /> Grout Seat Depth i1 = Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack rnixI7 gat water <br /> C1 Bentonite(20%solids) a Other <br /> Grout Placement Method -i Pumped I-. Free Fall C Other i Rotarclant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor L Other <br /> Concrete Pedestal Dimensions:Width 't Length It Thick in Christy Box L Stove Pipe <br /> PUMP )(Submersible❑ Turbine .. Other HP _ Pump SOt ft Standing Water Level ft <br /> I HEREGY 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 COM4ENUXON LAWS. <br /> NIM {OUR ADVANCE NOTICE REQUIRED FOR INSPECTION: <br /> SIGNED / TITLE CEO DATE <br /> # ` Pump is located behind the first <br /> - house off of Priest.South East of <br /> 10349 <br /> -• .' <br /> { <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L Date 3 JS 0.70 Area /h Employee ID# ")CA <br /> Application <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By �fpvy:5sr ca"a hL L Date ..91IgllA�v WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> W 0040 <br /> 1 <br /> EHD 43.06 <br /> 8/04108 WELL/PUMP PERMIT <br />