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#5254 WELL / PUMP PERMIT <br /> 'iAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 31L°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS; EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBAL`DRESS 11808 N. Ham Lane _ CITY/ZIP Lodi 95241D _ a <br /> CROSSSTREET Armstrong APN 059-230-12 }-'79 °o <br /> PARCEL Sl"LE C LgND U5E APPLICATION{I � <br /> m <br /> OWNER NAME Russell Scott PHONE 369-5164 <br /> OWNER ADDRESS. same CITY/STATE/ZIP <br /> CONTRACTOR _Delta Stockton Pump PHONE 466-9625 <br /> CONTRACTORADDRE5S 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ffC-6l ❑D•09 ❑Other NUMBER 724778 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domesiic/Priva[e ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from owner- 'arcr yslem 'ame Contacl Name ar Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AlterationlModificalion ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) #ofwells ❑Soil Borings} #ofborings 0 Geotechnical or borings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump 1XPump Replace )em ❑Pump Repair _❑Cross-Connection Repair <br /> WELL CONSTRICTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Polnl ❑Other <br /> Proposed Well Depth ft Excavation_ in diameter ❑Open Bottom ❑Gravel Pack i Gravel Size in diameter <br /> ❑Conductor Casing in diamener Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched T ❑SLeel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941h hug/5-10gal warr,r) CI Sand Cement sock mix/7 gal water <br /> ❑Bentonite(20%solids) ❑ Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted p� <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑DrMer ❑Pump CoMMCTOf ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ . ft Lcnglh l'L Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP $I Submersible ❑Turhine ❑Other lip 1 Pump Set 105 ft Standing Water Level 87 ft ? <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 2L <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 /> n <br /> M IIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SICNED Y-4� TITLE CEO DATE 01/19/05 <br /> t <br /> i <br /> DEPARTMENT USE JONLY <br /> Application Accepted By Date C l?� Area l mpioyee ID# <br /> Grout Inspection.By Date _ ❑ SPECIAL Well Perrnit <br /> Pump lnspecuon By7� Date /� �C 1� ❑ WAIVER Received <br /> Destruction lnspection By Date Constructed Well Depth rt <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit! <br /> Code, Info B C sh Remitted bate Service Requestfl Invoiced We111D# <br /> EHD 43-02-006 WELL PUMP PERMI"I <br /> K/6704 <br />