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1924 WELL/PUMP PERMIT <br />AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IVVIV-1'CEFUNUA9LE t'ERMIT r, WWW.S Ov.Of /ena tAF'IKtZi 7 YEAR FROM UATE ISSUED <br />JOB ADDRESS 2456 Country Club Blvd. _ __ _ CITYIZIP Stockton/95204 <br />CROSS STREET Plymouth Rd- APN 123-04-008 PARCEL SIZE 0.54 LAND USE APPLICATION # <br />OWNER NAME BettCampora PHONE 209-817-3632_______ <br />OWNER ADDRESS SAME CITYISTATE/ZIP <br />CONTRACTOR Delta Pump Co. PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. CITY/STATFJZIP Stockton/CA/95203 <br />SUBCONTRACTORICONSULTANT _ <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITYISTATEIZIP <br />PHONE <br />LICENSE i GST X2-61 D-09 Other NUMBER 1055434 EXPIRATION DATE 713 1 1 2 02 3 <br />BILLING PARTY: OWNER CONTRACTOR 1 I SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE _i Domestic!Private X IrrigationrAgriculttiral - Industrial Water Quality Monitoring F Soil Sampling/Characterization <br />I Public Water System <br />f drererer `icr- Cwrcr. 'later Slstefn NarT.` Contact Name or Phone Number <br />TYPE OF WORK I New Well I Replacement Well Well Alteratiorl!Modifrcation Other <br />"I Monitoring Well(s) # of wells - Soil Boring(s) ant h-gnngs r Geotechnical <br />Out -Of -Service Well Out -Cit -Service Well Renewal Cross -Connection Repair <br />New Pump ')(Pump Replacement . I Pump Repair Raise Well Casrnq <br />Drilling Method ! Mud Rotary Air Rotary J Auger Ll Cable Tool Push Point Other <br />Proposed Well Depth It Excavation in diameter I I Open Bottom I Gravel Pack -Gravel Size in diameter <br />-i Conductor Casing in diameter ! Conductor Casing Depth It <br />Well Casing Diameter _ in Thick nessiGaugelASTM Sched I I Steel Plastic I Stainless Steel Other <br />Grout Seal Depth ft _ Neat Cement (94 /b bag/5- 10 gal water) _ Sand Cement sack mixi7 gal water <br />I Bentonite (20% solids) Other <br />Grout Placement Method Pumped -I Free Fall Othel I: Retardant! Accelerator (name) <br />PEDESTAL Installed By Driller Purnp Contractor Other l <br />Concrete Pedestal -IDimensions Width It Length It Thick in Christy Box -1 Stove Pipe <br />Pu@tP XSUbmersible Turbine Other HP 1.5 Pump Set 63 It Standing Water Level 12 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 />r r,_ v■/•InI'(I r rn w r�ai A.— . i.r --Al "-- h r: .r-, rain ear �•rt n,►rn nr rw nr `.w a :.•,n�,sero -r:, <br />SIGNED 1L— TITLE CE0 DATE 11/8/2021 <br />Codes <br />Info <br />DEPARTMENT <br />USE% ONLY <br />Remitted <br />Service R uest # <br />Application Accepted By <br />Z�1— <br />�I3 <br />Date <br />I I /I $ /�) <br />Area 1<�t ktJ� Employee ID# C <br />Grout Inspection By <br />Date <br />I SPECIAL Well Permit <br />Pump Inspection By <br />L� <br />�/ r bj� <br />/ <br />ate [ (Z ` <br />I WAIVER Received <br />PAYMENT' <br />a <br />RECEIVED, <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth <br />it <br />COMMENTS „/zjc`✓ <br />r,,(1SirI;�_ <br />tnl <br />� 7 2021? <br />, <br />-N JOAQUIN COUNTI(' <br />PE SC Received <br />Check#f <br />Amount <br />Permit/ <br />ENV MENTALr <br />Date <br />Invoice # <br />Well ID#11 ALTH o RTMEM <br />Codes <br />Info <br />B <br />C s <br />Remitted <br />Service R uest # <br />�I3 <br />opo <br />PA <br />REc <br />EHD43-36 r,171r_019 <br />AENI <br />'IVED) <br />7 M21 <br />,iAN JOArjUIN COUilty <br />LNVI"ONMENTAL <br />11LALTH DEPARTMENT <br />