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�11111111116.A 518 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 9438 N. Alhambra Ave.._ .._ n___CITYZP Stockton/95212 <br />CROSS STREET Morada APN .086-44-04!-7 _ PARCEL SIZE V. 7 LAND USE APPLICATION # <br />OWNER NAME Deborah Tyler _ PHONE209-66�-3843 <br />OWNER ADDRESS SAME_. CITYISTATE/ZIP <br />CONTRACTOR Delta. Pump Inc PHONE 209_466-9625_ <br />CONTRACTOR ADDRESS 6465. California St. CITY/STATE21PStockton/95203 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />PHONE <br />UcENse I C -Si x C-61 D-09 Other NUMBER 1055434 EXPIRATION DATE 7/31/2021 <br />BILLING PARTY: OWNER CONTRACTOR I SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE }Domestic?Private Irrigation:Agricultural - Industrial - Water Quality Monitoring r' Soil Sampling/Characterization <br />I Public Water System <br />If difrerent from Owrer. Water System Name Contact Name or Phone Number <br />TYPE OF WORK I New Well 1: Replacement Well Well Alteratiort%Modification Other <br />-1 Monitoring Well(s) # of wells -_ Soil Borings) or honr t, F Geotechnical u „r aor�gs. <br />I Out-Of-Servicc Well Out -Of -Service Well Renewal Cross -Connection Repair <br />I New Pump X Pump Replacement _1 Pump Repan Raise Well Cas,na <br />Drilling Method -i Mud Rotary i_ Air Rotary a Auger U Cable Tool Push Point _ Other <br />Proposed Well Depth ft Excavation in diameter I Open Bottom i I Gravel Pack.Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness Gauge:ASTM Sched I � Steel Plastic I Stainless Steel Other <br />Grout Seal Depth ft _ Neat Cement (941b baglS 10 gal water) _ Sand Cement sack mrxl7 gal water <br />I Bentonite (20% solids) I Other <br />Grout Placement Method _ Pumped U Free Fall Other L Retardant: Accelerator (name) <br />PEDESTAL Installed By Driller PUMP Contractor Other <br />I Concrete Pedestal nDimensions Width ft Length ft Thick in - Christy Box 11 Stove Pipe <br />PUMP XSUbmersible Turbine Other HP_1_ Pump Set 120 It Standing Water Level 96 h <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 />—4%U�� A? 1UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />SIGNED L TITLE CEO DATE 6/9/2021 <br />T <br />M <br />D <br />0 <br />0 <br />M <br />m <br />Area LI c/"/ Employee ID# -DA <br />SPECIAL Well Permit PAYMENT <br />WAIVER Received RECEIVED <br />Constructed Well Depth IL021 <br />:;AN JOAQt11N COUNTY <br />PE <br />Codes <br />DEPARTMENT <br />USE ONLY <br />Application Accepted By <br />J <br />2—/ — Date <br />o f <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />T <br />M <br />D <br />0 <br />0 <br />M <br />m <br />Area LI c/"/ Employee ID# -DA <br />SPECIAL Well Permit PAYMENT <br />WAIVER Received RECEIVED <br />Constructed Well Depth IL021 <br />:;AN JOAQt11N COUNTY <br />PE <br />Codes <br />SC Receiv <br />InfoOV <br />Check#/ Amount Permit/ <br />Cash Remitted Date Service R uest # Invoice # <br />N <br />Well ID# <br />Y39 <br />o f <br />EHD43-W 0'U12019 rd _.LL rI°Uh'I'f"J?`;Ill <br />