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1017 <br /> WELL/PUMP PERMIT <br /> SAN JoAQ=COUNTY ENVROmAENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AYENUE-STOCKTON CA 95205-6232 (209)4683420 <br /> NON-REFUNDABLE PERMIT www.qgov.org/ebd EXPIRES 1 YEAR FROM DATE Issum <br /> rn <br /> Joe ADDRESS 16425 W Clifton Ct Rd. _ CITY/2POCI(10n:95206 p <br /> D <br /> CROSS STREET Calpack Rd APN 189-25-028 f\'/I PARCEL SIZE 1800.68 LAND USE APPLICATION A d <br /> OWNER NAME ra <br /> Cat Ezane- mala .}.iylip �1,��,��ra,�•7U I' _ PHONE(209)969-2555 <br /> 55 up. <br /> OWNER ADDRESS zzs �l�a•_d�I3a bJ 1�l f ece.)-e CRYtSTATErztPTMM.CA-95=-�itejI 953- 10 <br /> CONTRACTOR Delta Pump,Inc. <br /> PHONE (20-9)4M9M <br /> CONTRACTOR ADDRESS 646 S.Calltomia St_ CITYJSTATEop Stockton,CA 955203 <br /> SURCONTRACTORJCONSULTANT PHONE <br /> SURCONTRACTORJCONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE 11 C-57 X C•61 D-09 Other NUMBER 1055434 ExPiRATK1N DATE 7131=1 <br /> BILLING PARTY: OWNER CONTRACTOR i i SUBCONTRACTORJCONSULTANT <br /> DOMESTIC WELL SAMPLING:-1 General Mineral/Coliform Bacteria(4391)-1 Dibrorrlochloropropane(4392)1 Arsenic(4393) <br /> INTENDEO USE X DornesticM'dvate 1 irrigatioNAgn"ural - Industrial -1 Water Ouatity Monitoring r Soil SamplinglCharacterization <br /> I Public Water System <br /> 'IcKwor"ran•�Yvcr Nl.!t.v ST•:q+n Nunn ---- uxi4.c1 Name w%hicx-4•t:urrriz• ---- <br /> TYPE Of WORK 1 Newt Well I Replacement Well Wel AlteratiorvModif"tion Other <br /> -1 Monitoring WeNs) N of wells - Soil Boring(s) °.a h"nm?. r Geolectmical <br /> I Out-Ol-Service Wet! OUt•Of•Sorvlce Well Renewal Cross Coniection Repair <br /> ..1 New Pump t_ Pump Repldcemcrt M Pump Repair Rarse Well Casurg V�D <br /> WELL CONSTRUCTION ��� <br /> DNllincl Method Mud Rotary L Ain Rotary U Auger U Cable Tool _ Push Point Other 22 <br /> O�D <br /> Proposed Well Depth ft Excavation n diameter i I Open Bottom I I Gravel Pack•Cravel Size qN ter <br /> J Conductor Casng IrT dcmreler / Conductor C.asulg Depth 11 (�R <br /> NEq�T �NME �NTy <br /> Well Casing Diameter_in TliicNness'Gauge!ASTM Schad I I Steel Ptashc i Stainless Steel gher H�Ep� TQ L <br /> Grout Seal Depth H _ Neat Cement(94 rD Cag•S IO Qat water) _ Sand Cement sack nhrr ga!water ENT <br /> ' Bentonite(20%solds) I Other <br /> Grout Placement Method Pumped J Free Fal Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal 101mensions'Width tt Length l Thick in Christy Box i i Stove Pipe <br /> PUMP <br /> _X Submersible.. Turbine _ Othel HP 1 Pump Set 61 It Standing Water Level 9 tt <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 /> CURREN I AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> r Js <br /> iU12,AUV#CE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209(953-7697 <br /> vIGNCO TITLE CEO OATS 09/18/2020 <br /> R <br /> Ilk - <br /> A <br /> DEPARTMENT USE/ONLY [� <br /> „ypNcslton Accepted By --�� �� Date 7.10V/,LJy}'U Area J1 r-/ Employer IDA) <br /> Grout Inspection Inspection By Date 1 _ SPECIAL Well Perillit <br /> Purnp Inspection By km\c; oa 6NXr " I� Date WfUVER Received <br /> Soil Boring Insp"n By Date -- Cautrucled Well Depth it <br /> COMMENISYer i I]t/M be, IS,rIOYf►?PGf/oils �p well /I7G1 GIS E-4—ld n/f i"( _ -- <br /> PE SC Received Check Amount Permit/ -- <br /> Codes InfoRemiNed Date Service R lust P Invoice V Well IDa <br /> y38a aSc7 7 0-yd <br /> e.'4,,r a• ----- <br />