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5a � <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONGIENTAL HEALTH DEPT 1368 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT .ALL(209)953-7697 FON EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS y� �/ m <br /> r "`+ CITI'ILIP..�1_L��Sl��IIILLLLti•Sl—titi��ll--- � 111 m <br /> D <br /> CROSS STREET S a 1 1r� µP,; 5 _-15J�0 ? PARCEL SIZE 5,�� LAND USE APPLICATION;- <br /> CROSS <br /> OWNER NAME 111 ('h a.l 1 Q S PHONE�`�/� m <br /> �a5 9 ��a y <br /> OWNER ADDRESS — S_R �_ CITY/STATE/ZIP <br /> CONTRACTOR ]Delta PlIfulp I I1C' PHONE ( 209 ) 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR Pi-ZONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE L 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 D Domestic/Private ❑ Irrigation/Agricultural ;Glndustrial ❑ Water Quality Monitoring i s Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: water ystem amo Contact Name or Phone Number <br /> TYPE OF WORK :i New Well Z Replacement Well ❑ Well Alteration/Modification D Other <br /> #of borings <br /> _ Monitoring Well(s) #of wells � Soil Boring(s) � Geotechnical C� <br /> Out-Of-Service Well E Out-Of-Service Well Renewal ❑ Cross-Connection Repair NIECE/V T' <br /> ;j New Pum 'u Pum Replacement - Pum Repair ❑ Raise Well Casingl• <br /> WELL CONSTRUCTION �� <br /> Drilling Method D Mud Rotary ❑Air Rotary D Auger ❑ Cable Tool ❑ Push Point ❑ Other cn 15 <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Si—NN�wJV��g��i��' tameter <br /> Well Casing Diameter ctor Casing iThickness/Gauge/ASTM Sc ed Conductor Casing Depth❑ Steel ❑ Plastic ❑ Stainless Steel HOther "ter�NTA� <br /> Grout Seal Depth ft C Neat Cement(94 lb bag15-10 gal water) 1 Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) 'u' Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall F. Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By l Driller ❑ Purnp Contractor C Other <br /> C Concrete Pedestal Dimensions:Width it Length It Thick in _; Christy Box Stove Pipe <br /> PUMP ZSubmersible❑ Turbine L: Other HP PLIIIII)SCA.L&Aft Standing Watcr Level 95 It <br /> I HEREBY 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 COM N ON LAWS. <br /> NIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNEG f, TITLE CEO <br /> DATE <br /> I <br /> 84 417Z MQC M�� <br /> lot <br /> 14� ! 1, 1 1 1 1 1-T I r I I 1 11 1 1 1 <br /> '1 <br /> v <br /> � , DEPARTMENT USE ONLY <br /> Application Accepted By /`/L'Z_ Date y S zc Area Em.pi�y­ID,•, DA <br /> Grout Inspection By (,� Date ! SPECIAL Well Permit <br /> Pump Inspection By_F�t, _ <br /> ScN (_Rx-t, 1W Date L_' �YL( -v WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Receivedec Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> '�38d Oso J&10422 q 15. 2v OPOttyo 21 <br /> EHD 43.06 <br /> 8704108 <br /> WELL/PUMP PERMIT <br />