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PUMP ft Pump Set ft Standing Water Level X S ubrnersible Turbine Other HP 1 5 <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 />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MV ta W UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> <br />TrTLE CEO DATE 3/10/2021 SIGNED <br />Date 3/23/d <br /> <br />Area -I/ ( Employee ID# <br /> <br />Date <br />Dale 6 /-a I SPECIAL Well Permit <br />I WAIVER Received <br />Constructed Well Depth <br /> <br />Date <br /> <br />ft <br /> <br />1312 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209)468-3420 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CrrY/ZiP Lodi/95240 <br />PARCEL SIZE 10.07 LAND USE APPLICATION # <br />PHONE 209-815-5512 <br />PHONE 209-466-9625 <br />CITY/STATE/ZIP Stockton/95203 <br />SUBCONTRACTOR/CONSULTANT <br /> <br />PHONE <br /> <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br /> <br />CITY/STATE/ZIP <br /> <br />LICENSE i C-57 x C-61 D-D5 Other <br /> <br />NUMBER 1055434 EXPIRATION DATE 7/31/2021 <br /> <br />BILLING PARTY: OWNER CONTRACTOR I I SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 1 General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) 1 Arsenic (4393) <br />INTENDED USE X Domestic/Private 1 IrrigationiAgricultural Industrial -7 Water Quality Monitoring r Soil Sampling/Characterization <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS 10989 N. Pearson Rd. <br />www.sjgov.org/ehd <br /> <br />CROSS STREET E. Eight Mile Rd. <br /> <br />APN 059-19-004 <br /> <br />OWNER NAME <br /> Roger Keener <br />OWNER ADDRESS SAME <br />CONTRACTOR <br /> Delta Pump Inc <br />CITY/STATE/ZIP <br />CONTRACTOR ADDRESS 646 S California St <br />Drilling Method <br />Proposed Well <br />, I Public Water System <br />if different from Owroi Water System Name <br />I Air Rotary LI Auger U Cable Tool _ Push Point <br />Excavation in diameter <br />J Conductor Casing in diameter Conductor Casing Depth <br />in Thick nessiGa ugeiASTM Sched I Steel <br />ft _ Neat Cement (94 lb bag/5-10 gal water) <br />, Bentonite 120% solids) <br />Contact Name or Phone Numb_ <br />Geotechnical <br />At4 R 2 <br />/SAN J04 <br />/.4 ,-..N1//,9(Y,A8,4N notvri, _ Other t" • <br />I Gravel PackiGravel t L__p,• tEN <br />Plastic I Stainless Steel Other <br />Sand Cement <br />TYPE OF WORK New Well I Replacement Well <br />11 Monitoring Well(s) # of wells <br />Out-Of-Service Well Out-Of-Service Well Renewal <br />New Pump I.. Pump Replacement XPump Repair <br />WELL CONSTRUCTION <br />Mud Rotary <br />Depth ft <br />Well Casing Diameter <br />Giout Seal Depth <br />I Other <br />Well Alteration/Modification Other <br />nt hnriivp Soil Boring(s) <br />Cross-Connection Repair <br />Raise Well Casing <br />Open Bottom <br />sack mail gal water SS3daCIV 311S Grout Placement Method . Pumped Free Fall _ Other <br /> <br />S Retardant Accelerator (name) <br /> <br />PEDESTAL Installed By Driller Pump Contractor Other <br />7 Concrete Pedestal - IDimen s ion s . Width ft Length It Thick in -- Christy Box 1-1 Stove Pipe <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By <br /> <br />Grout Inspection By <br /> <br />Pump Inspection By <br /> <br />Soil Boring Inspection By <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Bi <br />(Cheçj Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# CSh <br />1--13ec 0s-0alV. 02 s-S— -t, 77 3t1-312-1 VIPOD-1 <br />El-ID 43-06 60112019 <br />WELL /PUMP PERMI