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�p <br />2069 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209J 468-3420 <br />IVUnI-MtrurvUAl5Lt rtNMll www.sJgov.org/ena EXPI1<11=5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1102 W. Edan Ave.. �]GVCITYIZIP Stockton/95207 <br />G077-36-00.6 <br />CROSS STREET Garan Ave. _ APN 0!7 _I -J.-00.6_ _,PARCEL SIZE 0.31 LAND USE APPLICATION # <br />OwNERNAME Tim Schultz PHONE 209-471-2183 <br />OWNER ADDRESS SAME. CITY/STATEIZIP <br />CONTRACTOR Delta Pump Co. PHONE 209-466-9625 <br />CONTRACTOR ADDRESS _646 S. California St. CITY/STATE/ZIP Stockton/CA/95203 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE 1 C-5 XC -F 1 D-09 Other NUMBER 1055434 EXPIRATION DATE 7/31 (2023 <br />BILLING PARTY: OWNER CONTRACTOR LI SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />NTENDED USE X Domestic;Prn+ate -1 IrrigationiAgricultural - Industrial -1 Water Quality Monitoring r Soil Sampling/Characterization <br />1 Public Water System <br />If different from Owner. Water System Nark Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well i Replacement Well Well AlterationiModification Other <br />rt h nr ye, <br />Monitoring Well{s) # of wells _Soil Boring4 `1 s) fl Geotechnical # or n/�`+ <br />I Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump X Pump Re lacen-ent i Pump Repair Raise Well CasingV <br />WELL CONSTRUCTIONFEB* 7 <br />Drilling Method J Mud Rotary L Air Rotary 1 Auger u Cable Tool Push Point Other Qty I 2 <br />Proposed Well Depth ft Excavation in diameter I Open Bottom i I Gravel Pack:Gravel Size ENyTN�Rnr <br />J Conductor Casing in diameter % Conductor Casing Depth It ALTN L'EP ENT <br />Well Casing Diameter _ in Thick ness'Gauge;ASTM Sched I Steel Plastic I Stainless Steel Other ART I <br />Grout Seal Depth It _ Neat Cement (94 !b bag✓5- 10 gaf water) _ Sand Cement sack mix.+7 gal water <br />1 Bentonite (20% solids) F Other <br />Grout Placement Method _ Pumped J Free Fall _ Other L Retardant! Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal -(Dimensions Width R I ength It Thick in - Christy Box rl Stove Pipe <br />PUMP )(Submersible_ Turbine Other HP 1.5 Pump Set 40 It Standing Water Level _ _ 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 />It ''int: R IJ ?UR ADVANCE I. -NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2R„Qt 9551 -;.cg-' <br />SIGNED —_ ___-_ TtTLE CEO _ - DATE 2110/2022_ <br />DEPARTMENT USE ONLY <br />Application Accepted BY Date yr i 7,Z2.,% <br />Grout Inspection By _ Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area "/ Employee ID# PJA. <br />Y <br />I SPECIAL Well Permit <br />I WAIVER Received <br />Constructed Well Depth <br />ip <br />V 7' <br />=D <br />PE <br />Codes <br />Sc Received Chec <br />Info B ash <br />Amount <br />Remitted <br />a <br />Permit/ <br />Service R . ufA-1 # <br />Invoice # <br />Well ID# <br />EFID 43-06 6P112019 WELL /PUMP PERMIT <br />Ty <br />T <br />