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•w T <br />1 883 WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />Ivvrv-MLVUNUAULL rERMIT www.sjgov.org/ena EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5084 S.H" 99 E Frontage Rd CITYtZIP Stockton/95215 <br />'CROSS STREET Sunny Rd. APN 181-12-015 PARCEL SIZE _LAND USE APPLICATION # <br />OWNER NAME Koodep Singh SI'nck � i� fi PHONE 541-787-1733 <br />I <br />OI r l�1✓11�Y <br />WI4ER ADDRESS SAME CH, `� a 3� �I '44 r 1 �i"' fr': r CITYf$TATEfZIP_ <br />CONTRACTOR Delta Pump CO. _ T PHONE 209-466-9625 <br />CONTRACTOR ADDRESS _646 S. California St. _ CITY/STATE(ZIP StoCiCton/CA/95203 <br />SUBCONTRACTORICONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />-(CENSE f C-57 XC -61 D-09 Other <br />31LUNG PARTY: OWNER CONTRACTOR <br />CITY/STATE/ZIP <br />NUMBER 1055434 EXPIRATION DATE 7/31 /2023 <br />I I SUBCOHTRACTOR)CONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />NTENDED USE X Domestic: Private 7 IrrigatiorvAgricultural - Industrial - Water Quality Monitoring f Soil Sampling;Clwracterization <br />Public Water System <br />I •arirer `rein Owner. bV Lei Sysuyn Nay m, •, ixitacl Name or Rhone Numbe• <br />TYPE OF WORK i New Well I Replacement Well Well AlteratiorUModification Other <br />1 Monitoring Well(s) # of ;yells - Soil Boring(s) * nt bongs h Geotechnical <br />Out-Of-Sen+ice Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump }{ Pump Replacement I Pump Repan Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary J Auger LI Cable Tool _ Push Point Other <br />Proposed Well Depth ft Excavation in diameter 1' Open Bottom i Gravel Pack:Gravet Size In diameter <br />J Conductor Casing in diameter ! Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness Gauge:ASTM Sched I Steel Plastic I Stainless Steel Other <br />Grout Seal Depth ft _ Neat Cement (94 )b ba915- 10 gal water) _ Sand Cement sack MIA.?7 gal water <br />Bentonite (24% solids) I Other <br />Grout Placement Method Pumped J Free Fall Other I_ Retardant! Acceleiator (name) <br />PEDESTAL Installed By Driller - Pump Contractor Other 1 <br />Concrete Pedestal -(Dimensions Width ft Length ft Thick in Christy Box '1 Stove Pipe <br />Puny (Submersible_ Turbine Other _ HP 1 -25 Pump Set 100 It Standing Water Level 50 It <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 />WW <br />8 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 1209) 953-7697 <br />SIGNm TITLE CEO DATE 1 011 9/2 02 1 <br />� m <br />t, I ■ <br />■ <br />M! NEON ■■ i 01 <br />DEPARTMENT USE ONLY <br />Application Accepted By r`—'��� Date ID v� <br />Grout InspectionByiA Date ;_�171`) 1Z� <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />�- <br />Area r �I �7 Employee ID# A.6 <br />I SPECIAL Well Permit <br />WAIVER Received <br />Constructed W 1pepth ft <br />PE <br />Codes <br />SC Received Check <br />Info s <br />Amount Date Permit) Invoice # Well ID# <br />Remitted Service R _ uest # <br />L3.? <br />p S -C) <br />7 1r� <br />END 43 X, Or L_i7'9 <br />1 -41k - <br />(go <br />