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55 � <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 PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> Lodi i5 a�i n <br /> JOB ADDRESS � /(�{V Tuner er f� CITY/ZIP ! m <br /> `' O <br /> CROSS STREET Q e _ I,r,`lIt QS C L A//PPN oa5' -D,aa- —PARCEL SIZE V LAND USE APgfiPLICAtT`IO��N# [� m <br /> eo"el1a.-rFfw%k !' dIs PHONEAi 10,0`310.5 y <br /> OWNER NAME c /�� c y <br /> OWNER ADDRESS Ste}1 A G CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump Inc- PHONE (2(19) 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-61 ❑ D-09 ❑ Other NUMBER 1055434 EXPIRATION DATE 8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Gontact 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 it of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair N <br /> 77NewPump A Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUC i wN w <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Si ia��pj�r <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft F `10 <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel tb r; IA_C <br /> �® <br /> Grout Seal Depth ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sac l 1' <br /> ❑ Bentonite(20%solids) ❑ Other FNT <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ 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 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] AM IN COMPLIANCE WITH ALL <br /> WORKERS COMjjENUQON LAWS. <br /> NIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE /T <br /> _' <br /> *s4 W. .,.fb + <br /> 0 g*# . <br /> *# <br /> / DEPARTMENT USE ONLY -- - <br /> Application Accepted By Date '123 T DZ0 Area tjI tip Employee IDA <br /> Grout Inspection By Date SPECIAL Well Permit <br /> /� <br /> Pump Inspection By �fa��'.Sb 1 c cft:,., f'L. Date �JJR 12r' WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received _Check#b Amount Permit/ <br /> Codes Info B s Date Remitted Service Re uest# Invoice# Well ID# <br /> os-0 $7� <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />