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TYPE OF WORK 0 New Well LI Replacement Well 21 Monitoring Well(s) of wells Out-Of-Service Well - New Pump C Pump Replacement WELL CONSTRUCTION A UG 1 1 Drilling Method : Mud Rotary E Air Rotary 0 Auger C Cable Tool 0 Push Point 0 Other < 2020 S Ai ,_ Proposed Well Depth ft Excavation in diameter UOpen Bottom 7. Gravel Pacic'C-ravel ' UU/N in diameter /V 0 Conductor Casing in diameter / Conductor Casing Depth ft 1-14/-THR2,p.AltioMEg°,4U/N Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel .7. °tilers'-AR Tr -- MCN r Grout Seal Depth ft '2 Neat Cement (94 lb bag/5-10 gal water) '.-I Sand Cement sack ,n/x/7 gal water 4 El Bentonite (20% solids) 0 Other Grout Placement Method LI Pumped LI Free Fall E Other ii Retardant / Accelerator (name) PEDESTAL Installed Installed By 0 Driller C Pump Contractor b Other . Concrete Pedestal Dimensions: Width ft Length ft Thick in . Christy Box Stove Pipe Well Alteration/Modification LI Other # of borings 1, Soil Boring(s) Out-Of-Service Well Renewal X Pump Repair Geotechnical Cross-Connection Repair E Raise Well Casing Jos ADDRESS 2438 Morada Ln. Cirri-ZIP Stockton 95391 PARCEL SIZE 1.0 LAND USE APPLICATION I, PHoNE (209)981-4926 CROSS STREET Cherbourg Way APN 090-10-060 OWNER NAME Johny Chap CONTRACTOR Delta Pump inc. PHONE (209 )466-9 6 2 5 C-57 XC-61 D-09 0 Other NUMBER 1055434 EXPIRATION DATE 8/16/20 LICENSE GEOGRAPHICAL INFORMATION: Coordinates X Township Range Section INTENDED USE X Domestic/Private E Irrigation/Agricultural = Industrial D Water Quality Monitoring E Soil Sampling/Characterization D Public Water System It different from Owner: Water System Name Lomact Name or hono Ramer OWNER ADDRESS SAME CITY/STATE/ZIP 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 PHONE CITY/STATE/ZIP CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS 850 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East HazeIton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECi I EXPIRES 1 YEAR FROM DATE ISSUED PUMP X Submersible: Turbine Other HP 1 Pump Set 107 ft Standing Water Level 53 it I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COM N ON LAWS. :SS21100V 311S SIGNED 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION TITLE CEO DATE 7/17/2020 Mil 111111 Ell I .111 III __ moo lu ___ _ ..r 111 11 ,}.. . --TT, r , ______.___.-- r, _ . , • ., , • , - `. ) -, F . I . 1* 4 e A .• , al? 1 _ _ . 4 • 4 . 4.- . '4N --- - *. 4s I. . _ ... , ___ ...V 243 • ....._ VI: AllciraelInN -...\., . . . -':' . 0 ' . . __......---------------. & _ , • t' 14 • ibie :"^-1v 1 ...' t '4111 ' ' ..•.." 1‘,Ifis -......____ . : i ".t. i . ,,_ ..., %rill . 1 f. III . . ii .1 I - -- - - ii =ME MR MI MEI DEPARTMENT USE ONLY Date T//3/i.10c? 0 Area /^2b iD(./< I.° .-7 Employee 1011 FR , Date SPECIAL Well Permit Date 5./ Li .202 1 WAIVER Received Date Constructed Well Depth ft PE Codes SC Info By Received4e,saingpic s Amount Remitted Date Permit/ Service Request 4 Invoice # Well ID# 9 3 Igo? DSO /77 477 8.12-10 v\ipuNtot7..... Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS ?r,f CO) ue jirj p.v61k: ,_40fer END 43-06 WELL /PUMP PERMIT 8/04/08