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1 � <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />Ivvrv-rttrulvUAnL.t rttttwtI WWW.SJ ov.orgiena t:AFIKt5 7 YEAR FROM UATE ISSUED <br />JOB ADDRESS 1283 N. Alpine Rd. CITY/ZIP Stockton/95212 <br />CROSS STREET E. Victor <br />St/Hwy 26 APN 101-27-002 _ _ PARCEL SIZE 0-44 LAND USE APPLICATION # <br />OWNER NAMEy icttQA r Molina _ _ - __ - PHONE 209-292-7052 <br />(OWNER ADDRESS .SA__ME--._ ___-_ CITY.ISTATE/ZIP /� <br />CONTRACTOR Delta Pump Co. PHONE 209-466-%25 <br />CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIP Stockton/CA/95203 <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />CITYISTATE/ZIP <br />PHONE <br />LICENSE IC -57 XC -61 D-09 Other NUMBER 1055434 EXPIRATION DATE 7/31/2023 <br />BILLING PARTY. OWNER CONTRACTOR 1..1 SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE XDomesticr'Private -1 Irrigation;Agricultural - Industrial 71 Water Quality Monitoring f Soil Sampling/Characterization <br />I Public Water System <br />1difrerent from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK i New Well I Replacement Well Well AlteratioreModification Other <br />❑.,r <br />I Monitoring Well(s) # of wells - Soil BoringboI bonrjs s) F Geotechnical <br />I Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair 1. C <br />NeW Pump X Purnp Replacement -1 Pump Repair Raise Well Casin <br />WELL CONSTRUCTION O <br />Drilling Method Mud Rotary L Air Rotary .1 Auger U Cable Tool _ Push Point Other `SAN <br />Proposed Well Depth_ft Excavation in diameter I Open Bottom I i Gravel Pack:Gravv1L$V//�[ (ndlameter <br />J Conductor Casing In diameter / Conductor Casing Depth ftTH DFpART �NTy <br />Well Casing Diameter _ in ThicknesWGauger'ASTM Sched I Steel Plastic i Stainless Steel Other n1Fnr, <br />Grout Seal Depth ft _ Neat Cement (941b bag/5- 10 gal water) _ Sand Cement sack rnix;7 gal water <br />Bentonite (20% solids) 1: Other <br />Grout Placement Method __ Pumped U Free Fall _ Other U Retardant/Accelerator (name) <br />PEDESTAL Installed By Driller - Pump Contractor Other <br />Concrete Pedestal -]Dimensions Width R Length R Thick in - Christy Box I Stove Pipe <br />PunrP Submersible_ Turbine _Other HP —1-5— Pump Set 180 ft Standing Water Level 100 ft <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 />=_—Z— <br />M 8 SUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNEDTITLE CEO DATE 90l9171171 <br />l � J <br />Application Accepted By Date Area `� �/ c/ Employee ID# r� <br />Grout Inspection By .rte Date SPECIAL Well Permit <br />Pump Inspection By Date T/Z i WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Received (pheck# Amount Dat <br />Info B ash Remitted <br />Permill <br />Service R nest # <br />Invoice # well ID# <br />Ll 3 91 <br />3 s0 <br />E!4043 -X 5t+lr1]t9 <br />T <br />m <br />D <br />v <br />v <br />p <br />A <br />w <br />