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-3Ug <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 /> Jos ADDRESS �) L. V / -,P-,(` of CITYIZIP S C Q /On 95 Sao D <br /> n <br /> CROSS STREET7j2"Je. Ne eK I? APN "!G" O D� PARCEL SIZE 1jQk0j,6.qLAND USE APPLICATION it m <br /> Ln <br /> OWNER NAME PHONE 2/)9 -�j -aaoc 4 y <br /> OWNER ADDRESS PP d aZ176 SkiCITY/STATE/ZIP fSOaJ,br1i 953A6 <br /> CONTRACTOR Delta Eump Tric— PHONE (209 )466-962--, <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 ❑ D-09 ❑ Other NUMBER 1055434 EXPIRATION DATE 8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE it Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Public Water System <br /> If differonl from Ovmer. water System Name uomact Name or 11hone Numoer <br /> TYPE OF WORK New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> _ Monitoring Well(s) K of wells Soil Boring(s) #of borings Geotechnical of borings <br /> Out-Of-Service Well = Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump A Pump Replacement C Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -- Mud Rotary Air Rotary ❑ Auger 11 Cable Tool ❑ Push Point El Other <br /> Proposed Well Depth ft Excavation in diameter C 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 Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft u Neat Cement(94 Ib ba9/5-10 gal water) !7 Sand Cement sack mix/7 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 /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP A'Submersible;7 Turbine ❑ Other HP Pump Set=t' (Q_ft Standing Water Level !D7 ft <br /> 1 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 COM N ON LAWS. <br /> NIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE - -�V <br /> 1b job. <br /> +� rsldu small structure <br /> err f ;, 14 <br /> ilk, Olt <br /> . y acs <br /> 63 <br /> V 4b 04" <br /> i <br /> DAR MENT U E ONLY <br /> Application Accepted By )� ,Date Area_����� Employee ID" <br /> Grout Inspection By t� Date SPECIAL Well Permit <br /> Pump Inspection By �r Iillt.S LO �'Z,.h V _ Date Q J WAIVER ReceiVed <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well 10# <br /> Codes Info B Cash Remitted Service Request# <br /> / <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 8/04,08 <br />