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'19-11 <br />19'1 t WELL/PUMP PERMIT <br />JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />rcnmrr WWw.�j VV.UIyreLlu tArlKtJ 7 TEAR FROM DATE ISSUED <br />JOB ADDRESS_ 1.95? W Wagner Heights Rd __ CITY/ZIP StoCktonl95209 <br />CROSS STREET TI tomIOrnton APN 072-45-003 PARCEL SIZE 0.33 LAND USE APPLICATION <br />pp <br />OWNER NAME Lary CollinsPHONE 209-481-8(725 <br />OWNER ADDRESS SAME_ CITY/STATE/ZIP <br />CONTRACTOR Delta PumpCo. PHONE 209-466-%25 <br />CONTRACTOR ADDRESS 646 S. Califomia St. Cirry/STATE/ZIP Stockton1CA195203 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CRYISTATEIZIP <br />PHONE <br />LICENSE I C-57 Xc.-c'I D-00 Other NUMBER 1055434 EXPIRATION DATE 7/31/2023 <br />BILUNG PARTY: OWNER CONTRACTOR I I SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE XDomestieaPrnatc -1 IrrigationvAgricultural - Industrial - WaterOuality Monitoring F Soil Sampling/Characterization <br />Public Water System <br />Idff,•_ i, icn: 1.""_r. VVarsi :::�.�c..n "J,;n- t=,;r,u;c1 Plank of ��,�•nc fJwnte -- -- -- <br />TYPE OF WORK ! New Well I Replacement Well Well AlterationlModification Other <br />-t Monitoring Well(s) # of wells - Soil Borings) a of bongs F Geotechnical #cit bmng% <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump X Pump Replacement i Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary _ Air Rotary A Auger U Cable Tool _ Push Point _ Other <br />Proposed Well Depth It Excavation in diameter 1 Open Bottom I I Gravel PackrGravel Size in diameter <br />Conductor Casing in diameter ! Conductor Casing Depth ft <br />Well Casing Diameter _ in Thick ness'GaugetASTM Sched I Steel Plastic 1, Stainless Steel Other <br />Grout Seal Depth it _ Neat Cement (94 Ib bag4�5- 10 gai water) _ Sand Cement sack max17 gal water <br />I Bentonite (20% solids) IOther <br />Grout Placement Method Pumped Li Free Fall Other L Retardant? Accelerator (name) <br />PEDESTAL Installed By Driller PUMP Contractor Other <br />Concrete Pedestal -]Dimensions Width R I-ength ft Thick in - Christy Box rl Stove Pipe <br />LLU�MpX Submersible Turbine Other HP_1_ Pump Set 75 It Standing Water Level _ _2,�_ It <br />1 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 />unu^ m rw nr r.n, innn, nrn <br />SIGNIED- - TITLE CEO DATE 11/9/2021 <br />Mr <br />■I t <br />:I -Wagner Heights Rd Wagner Heights Rd Wagner Heights Ra - Wagner Heights Rd Wagner <br />MFIs <br />7� <br />�r"401 <br />MA as Pry i <br />t <br />�^ ` ramda B dd <br />3 ' <br />} <br />L1 i• y�. <br />■ momm MN <br />y� DEPARTMENT USE ONLY <br />Application Accepted By Date f� i <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />C�/ <br />Area � � / Employee ID# /j A, <br />i SPECIAL Well Permit PAYMENT <br />WAIVER Received RECEIVED <br />Constructed Well Depth <br />NOV 117 2021 <br />—--�AN;rOROUIN COUNTY <br />ENVIRONMENTAL <br />.HEALTH Q9MRTII)FLNS <br />PE SC Received Check#t Amount <br />Codes Info BjA Cash Remitted <br />Permit/ <br />Date Service Request # <br />Invoice# WellID# <br />38) iso 127 <br />EHO 43 X 6P Ir_1:'9 :'�_LL IPUIVP PERMIT <br />