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JOB ADDRESS 1150 W. Rivara Rd. crryar Stockton/95207 <br />CROSS STREET St. Carlo Ave. 'APN 077-37-025 PARCEL SIZE 0.40 LAND USE APPLICATKM # <br />OWNER NAME Susan Gale <br /> <br />PHONE 209-406-6473 <br /> <br />OWNER ADDRESS SAME CITY/STATE/ZIP <br /> <br />CONTRACTOR Delta Pump Co. PHONE 209-466-9625 <br /> <br />CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIP Stockton/CA/95203 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br /> <br />CITY/STATE/ZIP <br /> <br />LICENSE Ii C-57 XC-61 D-09 - Other NUMBER 1 055434 EXPIRATION DATE 7/31/2023 <br />PHONE <br />BiLuND PARTY: OWNER <br />CONTRACTOR I I SUBCONTRACTOR/CONSULTANT :SS32100V all S I3V) <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HiszELToN AVENUE - STOCKTON CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: 1 General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) 1 Arsenic (4393) <br />Area y I‘; Employee ID* <br />ft <br /> <br />INTENDED USE X Domestic/Private 1 IrrigatiorvAgricultural - Industrial -I Water Quality Monitoring r Soil Sampling/Characterization <br />Public Water System <br />(different from Owret Water System Name Contact Name or Phone Numbe, <br />II New Well I Replacement Well Well Alteration/Modification <br />1 Monitoring Well(s) # of wells Soil Boring(s) <br />I Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br />1 New Pump )(Pump Replacement J Pump Repair Raise Well Casing <br />WELL CONSTRUCTION OCT U 7 2021 Drilling Method J Mud Rotary L Air Rotary U Auger U Cable Tool _ Push Point _ Other SAN -,v <br />f, i <br />iA Qui <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom ii Gravel Pack/Gravel <br />J Conductor Casing in diameter / Conductor Casing Depth ft H Op t, NTAL <br />A R 7;rii"Nr <br />--- ,-- <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel Plastic I , Stainless Steel Other <br />Grout Seal Depth ft _ Neat Cement (94 /b bag/5-10 gal water) _ Sand Cement <br />I Elentonite (20% solids) I* Other <br /> <br />sack ma/7 gal water <br /> <br />Grout Placement Method _ Pumped Li Free Fall _ Other 1J Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller - Pump Contractor Other <br />1 Concrete Pedestal r1Dinnensions Width ft Length <br /> <br />ft Thick in - Christy Box n Stove Pipe <br />Pun. <br /> <br />XSubmersible_ Turbine _ Other HP 1.5 Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 COMPUANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />I JUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> TITLE CEO Dam 10/4/2021 <br />TYPE OF WORK Other PA ym # of bonngs Geotechnical 4" ise T <br />EIVED <br />SIGNED <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By Date )0 /64 <br /> <br />Grout Inspection By <br /> <br />Date I SPECIAL Well Permit <br /> <br />Pump Inspection By <br /> <br />Date A9---12-45.1/ I WAIVER Received <br /> <br />Soil Boring Inspection By Date <br /> <br />Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />(92ciOtY <br />L ash <br />Amount <br />Remitted te Permit/ <br />, Service Request # Invoice # Well ION <br />LI -Igi 0S-0 /X SI-2A 47 7 <br />Del <br />Oh li Ulk0 tig WIC- <br />EHr..) #3-06 EV. ir2si <br />WELL N'UNP PF_RWT