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33 <br /> )�- <br /> WELLIPLIMP PERMIT <br /> 6AN 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 INSi EC1 tof; EXPIRES I YEAR FROM DATE ISSUED <br /> J06 ADDRESS J 3 3 -3N• gQt4t] 1 RCy� CITY/ZIP �--iJ� (j D <br /> - dQ/n 55, <br /> CROSS STREET! Q NP ! iDQ ( PARCEL SIZEOC •Oy LAND USE APPLICATION <br /> J p(tel 4� <br /> OWNER NAG1E 2��// ��! PHONE �LJQJ• /�9's�j� 5 <br /> OWNER ADDRESS /�J'J3 Q N• /{�Q�`n�C7/� <br /> CIl"Y/STATE/ZII <br /> CONTRACTOR Delta Lump Z_fiic.,,_ PHONE (f!t)9) 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California St CITY/STATEIZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE C-57 CXC-6 i D-09 Other NUMBER 1055434 EXPIRATION DATE 8/1 6/2 0 <br /> GEOGRAPFIICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/PrivateIrrigation/Agricultural -- Industrial _ Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System-Name ame ontact Name or Phone Nuinuer <br /> TYPE OF WORK El New Well ❑ Replacement Well Well Alteration/Modification ❑ Other_ hi <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) a borings Geotechnical "4%oclvs® <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair �„�l <br /> New Pum 7, Pum Replacement um Repair 0 Raise Well Casing �'°1rR <br /> WELL CONSTRUCTION SAN JOA <br /> Drilling Method Mud Rotary ---Air Rotary - Auger ❑ Cable Tool ❑ Push Point ❑ Other E QV IN C <br /> RANME Py <br /> Proposed Well Depth It Excavation in diameter C Open Bottom ❑ Gravel Pack/Gravel SiCe LTH--DIpL)Aeter <br /> n Conductor Casing in diameter / Conductor Casing Depth ft &ENT <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic .-: Stainless Steel -. Other <br /> Grout Seal Depth ft C Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack tnix/7 gal water <br /> F! Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped i: Free Fall i=; Other L! Retardant/Accelerator(name) <br /> PEDESTAL Installed By ,-; Driller : Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length It Thick in j Christy Box ❑ Stove Pipe <br /> PUMP G Submersible)(Turbine Other HP W Pump Sut O 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 COP! JNA// —ON LAWS. <br /> SIGNED �e TITLE CEO DATE I_ls ao <br /> JIM <br /> PUMP/WELL is located approz.442.27 k.from <br /> LIMA RANG H - <br /> N.Royal Road <br /> ROYAL <br /> e <br /> • <br /> I I IF <br /> Aapfieabort Acceptca By Date Arca <br /> Grout Inspection By Date P CIAL Well Permit <br /> rs-e <br /> Pump Inspection By ei S to Ct�C�.L CVL Date ,2 ZJ Z WAIVER ROCeIV@CI <br /> Soil Bonng Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chee Amount Date Permit! Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> �' /J�� '7 Z�z� W P 00 0 7 <br /> EHD 43.Ou <br /> 8/04/08 WELL HUMP PERMIT <br />