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5 � a <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 /> Cn <br /> JOB ADDRESS Aa 341... W I n Q eve-e- Nd CITY/ZIP 13-6--Upt,t, / V.2 ma m <br /> CROSS STREET L�/l�l/�e c APN /89'�Ol / V' PARCEL SIZE +�Q LAND USE APPLICATION m <br /> OWNER NAME ) Q_/ J/n Q� PHONE Q 599 -,DU�( y <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump Inc- PHONE (2.f)9) 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 AC-61 L" D-09 ❑ Other NUMBER 1055434 EXPIRATION DATE 8/16/20 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private C Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Public Water System <br /> If difforonl from Owner: Water 6ystom Name uontact Namo or Phone Number <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> of borings <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) ❑ Geotechnical�� `ty, <br /> 2 Out-Of-Service Well C Out- Of-Service Well Renewal ❑ Cross-Connection Repair C/'Ar/' <br /> ;7 New Pum r- PumpReplacement um Repair Raise Well CasingC <br /> WELL CONSTRUCTION <br /> Drilling Method a Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point L, Other S. /y 3 27ow, <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel S' �© In diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft HSA CQUNT <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel C. Other D�pAFNrq- Y <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gat water) ❑ Sand Cement sack mix17 gal w ter <br /> ❑ Bentonite(20%solids) ❑ Other <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 It Thick in ❑ Christy Box ❑ Stove Pipo <br /> PUMP A(Submersible❑ 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM N ON LAWS. <br /> I NIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED �i i TITLE CEO DATE <br /> Q \ r <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee IU _ <br /> Grout Inspection By Date �^ SPECIAL Well Permit <br /> Pump Inspection By"IrC�tA1.3(o ,�1u, Date_c ZZ� QP?C WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> Codes Info B Date Cash Remitted Service Request# Invoice# Well ID# <br /> y39a os-o 1 3 Z #77 23 Z� hIP00 <br /> EHD 43-06 <br /> 8/04108 WELL HUMP PERMIT <br />