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7 <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 INS-P CTICN-, EXPIRES 'I YEAR FROM DATE ISSUED <br /> rn <br /> Jos ADDRESS 10365 Manthv Rd. CITY/ZIP Lathrop 95330 I Q1 <br /> D <br /> 0 <br /> (CROSS STREET Bowman Rd. APN 193-26-005 PARCEL SIZE 1498 LAND USE APPLICATION,.' +°� <br /> m <br /> OWNER NAME John Mendoza PHONE (209)627-7269 y <br /> I <br /> OWNER ADDRESS Same CITY/STATE/ZIP <br /> CONTRACTOR Delta PIltrIp lI1C:_ PHONE( irl)9 ) 466-96 -S <br /> CONTRACTORADDRESs 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C-57 AC-6-1 D-09 Othcr NUMBER 1055434 EXPIRATION DATE 8/1 6/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE X Domestic/Private Irrigation/Agricultural ❑ Industrial L. Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water ystom Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well D Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells D Soil Boring(s) »of borings Geotechnical -of Barin c <br /> Out-Of-Service Well D Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump X Pump Replacement ❑ Pump Repair ❑ Raise Well Casing �/ <br /> WELL CONSTRUCTION /� 1 '7' <br /> Drilling Method -- Ntud Rotary ,7 Air Rotary C Auger C Cable Tool Push Point ❑ Other .1 <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel S _--_ is&V <br /> -i Conductor Casing in diameter / Conductor Casing Depth �(/ <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel /RON N CD <br /> Grout Seal Depth ft = Neat Cement(94!b bag/5-10 real water) Ci Sand Cement sac!<r t,4 Iktor <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ❑ Pumped C Free Fall ;_: Othcr i Retardant/Accelerator(name) <br /> PEDESTAL Installed By C1 Driller Pump Contractor C, Other <br /> ❑ Concrete Pedestal Dimensions:Width It Length fl Thick in j Christy Box ❑ Stove Pipe <br /> PUMP R Submersible.-I Turbine -; Other HP I Pump Set 60 ft Standing Water Level 20 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. 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 COM N ON LAWS. <br /> Al�� <br /> NIM 24 HOUR ADVANCE NO IC'L`1�EQUMEV FOR INSPECTIONS <br /> SIGNED4TITLE- CEO DATE 6/5/2020 <br /> Pump is located under theroof �.=ry ,,- <br /> A <br /> . y ` 4 �L <br /> .T ;- ;". �Jar .• r . _.'-1 <br /> / DEPARTMENT U S E O N L Y <br /> Application Accepted By G� �!/ Date Area S Employee ID;" <br /> Grout Inspection By tn� Date SPECIAL Well Permit <br /> Pump Inspection By •SCi [ t_ �z t�� Date �� 1x`1.4�L� WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received heclk#N Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> N3fii ' Dr0 � 77IT V <br /> EHD 43.06 WELL/PUNIP PERMIT <br /> W04108 <br />