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1764 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />Iv vIY-r\cr U lY Lj A 0 Lc rtl[IVIII _ WWW.J1ljUV.U1 ylellu r_Ar'IrCCJ 1 1tAK rKL)M (JAIL ISSULU <br />JOB ADDRESS 9920 S. Airport Waw _ _ -, CITY!ZIP Manteca/95336 <br />CROSS STREET French Camp APN 177-08-008 PARCEL SIZE 1.51 LAND USE APPLICATION # <br />OWNER NAME Darrell Meeker ��f ___ PHONE 209-982-1939 <br />OWNER ADDRESS 9904_ S.Y.Y <br />_ Airport .ay _ _ _ CITY!STATE/ZIP Manteca/95336 <br />CONTRACTOR Delta Pump Co. _ PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. CrTY/STATEMP Stockton/CA/95203 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE I C-57 XG-61 <br />BILLING PARTY: OWNER <br />D-09 Other <br />CONTRACTOR <br />CITYISTATE(ZIP <br />NUMBER 1055434 ExPIRATION DATE 7/31 /2023 <br />II SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General MineraUColiform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE (Domestic/Private -1 irrigation/Agricultural - Industrial -1 Water Quality Monitoring nSoil Sampling/Characterization <br />Public Water System _ <br />I •Ji'rereM from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well 1. Replacement Well Well AlterationiModification Other <br />A oorm rc <br />Monitoring Well(s) # of wells -Soil Boring ++ nt bongs s) Il Geotechnical of <br />Out -0f -Service Well Out -Of -Service Well Renewal Cross -Connection Repair 41IG <br />New PumpPump Replacement _I Pump Repair _ Raise Well Casmci o1 - V(2 <br />T <br />rn <br />D <br />0 <br />0 <br />A <br />v <br />DI dling Method _i Mud Rotary L Air Rotary 1 Auger U Cable Tool _Push Point _ Other <br />Proposed Well Depth It Excavation in diameter I I Open Bottom I I Gravel Pack!Gravel Size F <br />Conductor Casing in diameter I Conductor Casing Depth ft niF <br />Well Casing Diameter _ in Thickness`Gauge;ASTM Sched I I Steel Plastic I Stainless Steel Other <br />Grout Seal Depth ft _ Neat Cement (941b bag15- 10 gal water) _ Sand Cement sack mW7 gal water <br />Bentonite (20% solids) I Other <br />Glou( Placement Method _ Pumped U Free Fall _ Other U Retardant i Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor - Other <br />-1i Concrete Pedestal -]Dimensions Width R Length It Thick in - Christy Box I Stove Pipe <br />PUMP X Submersible Turbine _ Other HP_a_ Pump Set 83 It Standing Water Level 30 It <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 />=J','v1 jd H .SUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE CEO DATE 8/18f2021 <br />- 7JI ; <br />�' � � ' �"• \ 1. _ <br />240 <br />C��li , �o / t \1• <br />�• K <br />( 1 � 1• F , , <br />Y � • K <br />I <br />/ l D E P A R T M EN T U S E ONLY <br />Application Accepted By �—` L� Dale `1 I Area _ '1 <br />Application Employee ID# �v <br />Grout Inspection By Date _ I SPECIAL Well Permit <br />Pump Inspection Byahal <br />^ _1 Date I WAIVER Received <br />Soil Boring Inspection By Date COn5trllCted Well Depth It <br />COMMENTS <br />PE SC Received Check# <br />Codes Info B <br />Amount Date Permitl <br />Remitted Seri Re ue # <br />Invoice # Well ID# <br />y3�� o,•� S <br />��7 � I 1 <br />I:�, 4 t -W r,. P"', 'I <br />