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35g <br /> WEL L I"PUMP PERfi T <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKT ON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE"PERMIT CALL(209)953-76)97 FOR iN PEC'i i0ig6 EXPIRES 'I YEAR FROM DATE ISSUED <br /> Jos ADDRE60 � m <br /> 33Z E . J \e / i I cn A(.J� CITY/ZIP ��k+nn /5,20 m5 D <br /> 0 <br /> CROSS STRCCT___.� S�n .4Pi 1 Da- 61 3 PARCEL SIZE /•a 7 LAND USE APPLICATION," <br /> m <br /> T Q ^wJ <br /> OWNS^NA61C —�/_(1.C � / L. f� PHONE <br /> OWNERADDRESS SA G CITY/STATE/ZIP <br /> CONTRACTOR delta Pump lilt'- PHONE ( 2o9 ) 466-9625 <br /> CONTRACTORADDRESS 646 S. California St CITYISTAFEE./ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE C-57 XC-61 D-09 Other NUMBER 10 5 5 4 3 4 EXPIRATION DATE 8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private 0 Irrigation/Agricultural 1 Industrial L Water Quality Monitoring Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Ovmer. water bystern Narne Goniact Name or J1hcne Nurnuer <br /> TYP-OF WORK 0 New Well 0 Replacement Weil 7 Well Alteration/Modification U Other <br /> ❑ Monitoring Well(s) #of wells L Soil Boring(s) #of borings Geotechnical #of borings <br /> ❑ Out-Of-Service Well Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> New Pump Vurnp Replacement 0 Pump Repair - Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Mcthod Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom _ Gravel PacldGravel Size in diameter <br /> L] Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft C Neat Cement(94 lb ba9/5-10 gal water) !7 Sand Cement sack mix/7 gal water <br /> 11 Bentonite(20%solids) ❑ Othcr <br /> Grout Placement Method Pumped L Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By .:i Driller ; Pump Contractor L Other <br /> Concrete Pedestal Dimensions:Width it Length fl Thick in Christy Box Stove Pipe <br /> PUMP X.Submersible._ Turbine -: Other HP Pump SetftStanding Water Levcl 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 COMIJENUZON LAWS. <br /> SIGNED TITLE CEO DATE <br /> �t 1 <br /> -I <br /> sawoq <br /> gloq saalnuas dwnd aql <br /> -Aeon aAlap Oml aql uaamlaq <br /> palea01sl113M/dWfld • • - ' <br /> DEPA 7fJIENT USE ONLY <br /> Applicc;:or.Accepted By �' III/l /�- Date 7/D Area Z ,plc,:e ID;: <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By�GJ`t��19C �uTn,z~ f`Lv'L Date: <br /> �� L� WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request 1/ <br /> i <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 8/04108 <br />