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3 ) D <br /> 4 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 /> J06 ADDRESS SIDI /P c d, CITY/ZIP m <br /> CROSS STREET (wr SfAM&40 AP QO S' /7� 0 d PARCEL SIZELAND USE APPLICATION m 0 <br /> / I in <br /> m <br /> OWNER NAME 09,- PHONE j(t PPHOONE ;-0n 5179- <br /> - 179- 16 14 <br /> -�--�1 i y <br /> OWNER ADDRESS / U y�f, fr^�hQ at K- CITY/STATFJZIP_ LL f/n/a� op ad <br /> . r <br /> CONTRACTOR -Delta Ptimp T n C'_ 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 D-09 ❑ Other NUMBER 1055434 EXPIRATION DATE 8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 5 Domestic/Private Xrrigation/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 /> Z <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Weil Alteration/Modification ❑ Other � — <br /> Monitoring Wells) #of wells Soil Boring(s) of bodngs E Geotechnical #of bori 0 tj <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection R air � <br /> New Pump 7j Pump Replacement um Repair 7j Raise Well Casin M <br /> WELL CONSTRUCTION X E <br /> Drilling Method _- Mud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other (` CES VED D <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PacAPRvVVe (-03"iamet <br /> 7j Conductor Casing in diameter / Conductor Casing Depth ft UU 00 � m <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ 9 r _ <br /> ��sl/Iru'c� <br /> Grout Seal Depth ft C Neat Cement(94 lb bag/5-10 gal water) EN <br /> E) Sand Cemen VIRpNM <mix"c7' 17�al water <br /> !l Bentonite(20%solids) ❑ Other- ARTMENT <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 ❑ Stove Pipe <br /> PUMP ❑ Submersible Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> [ 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 C;TZN LAWS. <br /> i NIM 2�1 HOUR DVAVCE NOTICE= REQUIRED FOR INSPECTION'S <br /> SIGNED_ TITLE CEO DATE3701 <br /> / ^� <br /> ai. <br /> R Rd EPeftie—rj9d_!1L0-7 <br /> fe <br /> r • Please nON <br /> te the vineyard has <br /> ioved since photo. <br /> i.E Pel' <br /> DEPARTMENT US <br /> r <br /> Application Accepted By 2G L Date -LoL0 Area ��CC Employee IDI: _ <br /> Grout Inspection By Date� f SPECIAL Well Permit <br /> Pump Inspection By ��w^(.,S't;� �F�lt,aar ; L Date l <br /> l� -WqA WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Receivedheck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B s Remitted Service Request# <br /> `138a os-o 800 47? <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 8104108 <br />