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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 /> • ' ( rn <br /> JOB ADDRESS I 1 W % �� 7 CITY/ZIP �k f6 n 95,-2o(p n <br /> 1 0 <br /> CROSS STREET' APN !�9-211) L/)l,;-) PARCEL SIZE yLAND USE APPLICATION t �( A <br /> OWNER NAMEFarms4 <br /> PHONE 11b- 71 7- 9i�6S j� y <br /> OWNER ADDRESS �, 'b CITY/STATE/ZIP YVQInO (2m V e- 95 L�V <br /> CONTRACTOR Delta Pwnp Inc- PHONE ( 2o9)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 C-57 EXC-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 Contact Name or Phone Number <br /> TYPE OF WORK `7 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> Monitoring Wellof borings #o b <br /> Well(s) #of wells Soil Boring(s) ❑ Geotechnical <br /> Out-Of-Service Well C Out-Of-Service Well Renewal ❑ Cross-Connection Repair C'g-/;rY <br /> New Pum Pum Replacement ❑ Pum Repair ❑ Raise Well CasingV <br /> WELL CONSTRUCTION /�[� 13 <br /> Drilling Method ❑ Mud Rotary ❑Air Rotary ❑ Auger C Cable Tool 11Push Point 11Other S4 7ni <br /> Proposed Well Depth it Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel S' , }�ke'ter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft ATF/ M'EF�l11 <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel C Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixl7 gal water <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 ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> - <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 i <br /> WORKERS COMIJENUQON LAWS. <br /> I NIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPEECTIONS <br /> SIGNED . -_ TITLE CEO DATE <br /> Inside small building ' <br /> Mod - <br /> Vow <br /> DEPARTMENT USE ONLY /y <br /> Application Accepted By i t7„Jg)i����; Date /� BOZO Area 3 q% Employee IDfP SJkhreP <br /> Grout Inspection By Date / SPECIAL Well Permit <br /> Pump Inspection By �rtwtl,1Q7 � 1 Date 1 hp2v WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck#/ Amount Date Permit/ # Well ID# <br /> Codes Ch <br /> Info B Remitted Service Request# <br /> y3g� iso �l 77 'wVO �A0 2 <br /> EHD 43.06 <br /> 8/04108 WELL/PUMP PERMIT <br />