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% WELL/PUMP PERMIT SAN.iOACUIN COUNTY ENVIRONMENTAL HEALTH DEPT '1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT (209)953-7697 roh iiJSFECTioNs EXPIRES 1 YEAR FROM DATE ISSUED 3 7 35- T Shc+a�, G5a oc� Zi JOB ADDRESS / rrl �� CITY/ZIP m CROSS STREET �(� APpt o v q�C�. 175-a� "`Ov PARCEL 51zEQ �LAi4D USE APPLICATION;` f/ m OWNER NAME n� P 4 L�m/ i&- Pores PHONE�-. [7 3— %, ?Q y OWNER ADDRESS S4 1A E CITY/STATE/ZIP CONTRACTOR Delta Pump 1f1C:_ 131-IONE ( 209 ) 466-9625 CONTRACTOR ADDRESS 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 AC-61 D-09 ❑ Other NUMBER 1055434 EXPIRATION DATE 8/1 6/2 0 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial !_. Water Quality Monitoring Soil Sampling/Characterization Public Water System If different from Ovmer: :.a;ur tiystom Name Con;ac;R Rame ane Numuer TYPE OF WORK ❑ New Well ❑ Replacement Well = Well Alteration/Modification ❑ Other C.of borings nc Monitoring Well(s) #of%yells Soil Boring(s) Geotechnical P "1 Out-Of-Service Well C Out-Of-Service Well Renewal D Cross-Connection Repair E / New Pum a Pump Replacement )ePump Repair Raise Well Casing WELL CONSTRUCTION Drilling Method _- Nlud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point C Other APR 2�Z Proposed Well Depth ft Excavation in diameter ❑ Open Bottom a Gravel Pack/Grava'$.44b In diQuter ❑ Conductor Casing in diameter / Conductor Casing Depth ft HEW/ COUNT Well Casing Diameter— in Thickness/Gauge/ASTM Sched ❑ Steel Plastic ❑ Stainless Steel Q�ah�� E Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-70 gal dater) CI Sand Cement sack 101x11AItcr 11 Bentonite(20%solids) C Other _ Grout Placement Method ❑ Pumped F: Free Fall :- Other Retardant/Accelerator(name) PEDESTAL installed By Driller Pump Contractor ❑ Other Concrete Pedestal Dimensions:Width It Length it Thick in Christy Box ❑ Stove Pipe PUMP Submersible:_ Turbine Other HP L_ Pump Sot /Z0 ft Standing Water Level l HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNT`! ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COPA N ON LAWS. s I SIGNED TITLE CEO DATE PUMP/WELL Is located just j behind the 2 door aara�e. r'h— i 2 Car Garage — awl l DEPARTMENT USE ONLY --- Application Accepted By ,--J7_42, Date 1,271W 20 Arca/�� loyc�IZ D �J a Grout Inspection By Date SPECIAL AWpelll•'Pejrmit Pump Inspection By '4! G�nL S� �cwll c (,1'1. Date WAIVER AMIL A 20 Soil Boring Inspection By Date Constructog W,glWoontI HEALTW—fi $f.",'°l",OMMENTS - RERM1T/S€RVlO€S a PE SC Received Q Check Amount Date Permit/ Invoice# Well ID# Codes Info B Remitted Service Request# 93�a asa45 7? 2J-2D EHD 43-06 WELL/PUMP PERMIT 8/04108