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151 <br /> 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 /> JOB ADDRESS SKCITY/ZIP L-SCCL 160 m <br /> /�/{��-r T� J- ,y C� a <br /> CROSS STREET 8eiQ ( 6n 9,APN 2-D r-&-DDI PARCEL SIZE7q,/, 0 LAND USE APPLICATION t <br /> M <br /> OWNER NAME r/P/��� c 1 t� r �JPHONE <br /> 269- 6502 -61 2 y <br /> OWNER ADDRESS �,Q-, 1 tL v 1 / �.(,{� CITY/STATE/ZIP ESCL�Ihn 9�"32C� <br /> CONTRACTOR Delta YLlfnip Tric- PHONE (209)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-57 CXC-61 a 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 -A Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Uontact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells Soil Boring(s) 9 of borings Geotechnical I of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement KPump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ (Mud Rotary ❑ Air Rotary C Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 7, Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched :iSteel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seat Depth ft C Neat Cement(94 Ib bag15-10 gal water) -i Sand Cement sack mix17 gal water <br /> iI 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 it Thick in ❑ Christy Box ❑ Steve Pipe <br /> PUMP ❑ Submersible; Turbine ❑ Other HP Pump Set ft Standing Water Level it <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. 1 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 COMWNSA11ON LAWS. <br /> i NIN i 24 ;1OUR ADVANCE (NOTICE REQUIRED OR INSPECTION'S <br /> SIGNED yY TITLE CEO DATE /0 ��2 <br /> r <br /> 1 'r r'� . — <br /> �i <br /> FNr <br /> INFO <br /> t�- N <br /> ?019 <br /> oUA1 <br /> TqC n' <br /> MFHT <br /> ARTMENT USS LY <br /> Application Accepted By !JV Date / O IL Area Employee ID-4tow <br /> Grout Inspection By t1 Date p PECIAL Well Permit <br /> Pump Inspection By rtr.r.Ste �QuY`, +�a Date f �r�p'1_ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By cash Remitted Service Request# <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 8/04!08 <br />