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17 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468.9420 <br />IVVN-KEFUNDABLE PERMIT www.sjgov.org/end EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5748 E. State Route 4 CITY/ZIP Stockton/95212 <br />C ROSS STREET Walker Ln. APN :' 7 `N � 3 o I I PARCEL SIZE 56.43 LAND USE APPLICATION # <br />OWNER NAME Ron Sanguinetti/J&R Sanguinetti - <r..nc� N6 Ei;rM PHONE 209-607-9229 <br />OWNERADDRESS 18638 E. Copperopolis Rd. CITYISTATE/ZIP Linden/95236 <br />,CONTRACTOR Delta Pump Co. PHONE 209-466-9625 <br />(CONTRACTOR ADDRESS 646 S. California St. CITYISTATE/ZIP Stockton/9523 <br />UBCONTRACTORICONSULTANT PHONE <br />UBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br />ICENSE n C57 R C-61 F D-09 Other NUMBER 1055434 EXPIRATION DATE 7/31/2021 <br />ILLING PARTY: I_ OWNER _ CONTRACTOR U SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (439 1) -1 Dibromochloropropane (4392) -1 Arsenic (4 393) <br />INTENDED USE X Domestic/Private n Irrigation.+Agricultural - Industrial -1 Water Quality Monitoring F Soil Sampling/Characterization <br />I I Public Water System _ <br />If different from Owner. Water System Name Centa& Name or Phone Number <br />TYPE Or- WORK LI New Well U Replacement Well Well Alleration/Modification Other <br />s <br />FI Monitoring Well(s) # of wells -Soil Boring # of burins) g fl Geotechnical <br />Il Out -Of -Service Well Out -Of -Service Well Renewal - Cross -Connection Repair <br />U New Pump X Pump Replacement U Pump Repair _ Raise Well Casino 1F A <br />VVELL l:ON57RUG TION 1tJ <br />Drilling Method U Mud Rotary U Air Rotary U Auger U Cable Tool L Push Point J Other SAN `�O <br />Proposed Well Depth R Excavation in diameter 0 Open Bottom CI Gravel Pack/GravelRO <br />U Conductor Casing in diameter / Conductor Casing Depth ft�R? <br />Well,Casing Diameter _ in Thickness/Gauge/ASTM Sched U Steel _ Plastic 0 Stainless Steel := Other N% <br />Grout Seal Depth R Neat Cement (941b bag/: -10 gat water) _ Sand Cement sack mW7 gal water <br />Il Bentonite (20% solids) Cl Other <br />Grout Placement Method L Pumped U Free Fall Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller Pump Contractor F Other <br />rl Concrete Pedestal rlDimensions: Width R Length ft Thick in - Christy Box f1 Stove Pipe <br />PUMP Submersible_ Turbine Other HP 5 Pump Set 126 R Standing Water Level 75 R <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 />DEPARTMENT USE ONLY <br />Application Accepted ByDate (7Iwl <br />/� <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date \O <br />Date <br />Area / X14 Employee ID# 6 <br />❑ SPECIAL Well Permit <br />f 1 WAIVER received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ Amount <br />Remitted <br />Permit/ <br />Date Service Request # Invoice # Well ID# <br />c 3y1 <br />o:�Q) <br />4-77 <br />01 A& 124 ;�- <br />EHD 43-06 6/11/2019 WELLlPUMP PERMIT <br />