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1531ir <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IVUIV-KEFUNDABLE VERMIT WWW.sjgoy.orglend EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1092 E. Peltier Rd. CITYIZIPAcampo/95220 <br />CROSS STREET Lower Sacramento St. APN 013-14-002 PARCEL SIZE 1 9.39 LAND USE APPLICATION # <br />OWNER NAME Glen Reich PHONE 209-481-2867 <br />OWNER ADDRESS SAME CITYISTATE/ZIP <br />CONTRACTOR Delta Pump Co. PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIP Stockton/CA/95203 <br />S UBCONT RACTORICONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />_ICENSE i C -i7 XC -61 D-09 Other <br />BILLING PARTY: OWNER CONTRACTOR <br />C ITYIS TATE/ZIP <br />NUMBER 1055434 EXPIRATION DATE 7/31 /2023 <br />II SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: J General Mineral/Coliform Bacteria (4391) J Dibromochloropropane (4392) J Arsenic (4393) <br />NTENDED USE -1 Domestic: Private X IrrigatiorvAgricuftural - Industrial - Water Quality Monitoring f Soil SamplingiCharacterization <br />i Public Water System <br />f different from Owner. Water System Name Contact Name or Phone Numtx� <br />TYPE OF WORK i New Well I Replacement Well Well AlterationiModification Other <br />1 Monitoring Well(s) # of we�+nt hnrirg5 N,T,lls -Soil Boring(s) I- Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump X Pump Replacement A Pump Repair - Raise Well Casing <br />WELL CONSTRUCTION A � �Jlu r �C] D 202 <br />Drilling Method _j Mud Rotary L Air Rotary J Auger U Cable Tool Push Point _ Other <br />Proposed Well Depth 11 Excavation in diameter 1 I Open Bottom I I Gravel PackrGrave 'AQ[J._jf�f_�,ip dia� eter <br />J Conductor Casing in diameter / Conductor Casing Depth It HEALTH NMENTAL Y <br />Well Casing Diameter _ in Thickness Gauge?ASTM Sched I I Steel Plastic I Stainless Steel OtherPARTMENT <br />Grout Seal Depth ft - Neat Cement (94 lb bag/S 10 gal water) _ Sand Cement sack mix.7 gal water <br />i Bentonite (20% solids) I Other <br />Grout Placement Method Pumped . I Free Fall Other L Retardant f Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal -]Dimensions Width ft Length ft Thick in Christy Box 1 Stove Pipe <br />Purim Submersible- lufbme Other HP 20 Pump Set 100 —it Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 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 />NOTICE evrs)�^ �'^' � ",!SPE DC el"I" ^Ape OF CA CC r1A - <br />38 <br />ADVANCE dOTt E REQ M ­ <br />TITLE <br />S t^ Nom[ TITLE DATER/1 112091 <br />'1ft{ -- <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date _ IJ Area N_J144i Employee IDR_ <br />Date 0 1 SPECIAL Well Permit <br />Date 2 I WAIVER Received <br />Date Constructed Well Depth <br />MIT <br />PE SC <br />Codes Info <br />Received Amount Permit/ <br />Date Invoice # <br />B ash Remitted Service Request # <br />Well ID# <br />~;or <br />7 7 EA <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date _ IJ Area N_J144i Employee IDR_ <br />Date 0 1 SPECIAL Well Permit <br />Date 2 I WAIVER Received <br />Date Constructed Well Depth <br />MIT <br />PE SC <br />Codes Info <br />Received Amount Permit/ <br />Date Invoice # <br />B ash Remitted Service Request # <br />Well ID# <br />qT�i <br />7 7 EA <br />E1D043X r,11U2019 ;`c_LL_'PUn•f'f=Nour <br />