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S6 -6- <br /> WELL/PUMP <br /> PERMIT <br /> SAN JOAQUIN COUNTY L-NVIRONMEN TAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> MR, <br /> /- I <br /> JOB ADDRESS 7 !�W o`r�n qv ie-, CITY/ZIP �*6C1'1 9s a o � "' <br /> D <br /> CROSS STREET �OQ f\ APN Q /7" 3o? D0(p PARCEL SIZED, 3 LAND USE APPLICATION F- �/� m <br /> OWNER NAME S1 Iy i Q 3�(+/Sl'Q PHONE 2a!2-"" 4145 N <br /> SA <br /> /� ea <br /> OWNER ADDRESS SA M-&— CITY/STATEIZIP <br /> CONTRACTOR Delta P131u ] 1f1C:_ PHONE ( ,1o9 ) 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California St CITYISTATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS <br /> i� CITY/STATEIZIP <br /> LICENSE C-57 r-Xc-c,i D-09 E Other NUMBER 1055434 EXPIRATION DATE 8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE XDomestic/Private ._ Irrigation/Agricultural -- Industrial ❑ Water Quality Monitoring Soil Sampling/Character ation <br /> ❑ Public Water System p <br /> If different from Ovmer. WaterbyStain amoone ac;cmc or? anh e T u-n ;cr <br /> TYPE OF WORK �j New Well ❑ Replacement Well Well Alteration/Modification ❑ Other <br /> orin,: <br /> ❑ Monitoring Well(s) ftof wells Soil BoringS of borings <br /> Boring(s) � Geotechnical <br /> ❑ Out-Of-Service ' Out-Of-Service Well Renewal ❑ Cross-Connection Repair SAN 2 <br /> 02 <br /> D low Pump ump Replacement Pump Repair P Raise Well Casing P+✓Oq�, <br /> WELL CONSTRUCTION � � M <br /> Drilling Method (vlud Rotary Air Rotary ❑ Auger C Cable Tool ❑ Push Point ❑ Other ACTh0FF'gRNO TY <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size ,in di�t�Ter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ElSteel ❑ Plastic ❑ Stainless Steel - Other <br /> i <br /> Grout Seal Depth ft C Feat Cement(94 Ib bag/5-10 gal water) it Sand Cement sack mix/7 gal water <br /> 11 Bentonitu(20%solids) G Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall Other i. 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 I IEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNT`( 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 COMUIENUQON <br /> /LAWS. <br /> If ; <br /> SIGNED— -�__ IITLG CEO DATE <br /> Q7t <br /> '771 or <br /> .... . <br /> Application Accepted By r-1, Date ZO Area1-2� -ff m`ploy-�e T6,—, � <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By F'rcu'LCt� a <br /> �s�l (� Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check# Amount Date Permit/ Invoice# I Well IDI/ <br /> Codes Info B as Remitted Service Request# <br /> y3x1 osa ��� $ 7 `��-23 Zv WPON U1SZ <br /> EHD 43.06 --- -- --- - - <br /> af04108 WELL/PUMP PERMIT <br />