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#7409 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 31O FL-STOCKTON CA 95202 -(209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 172 N. Patton Road CITY/ZIP Stockton 95215 <br /> CROSS STREET Copperopolis Road APN 103-100-34 PARCEL SIZE' LAND USE APPLICATION# V <br /> OWNERNAME Vernon Ragsdale PHONE 465-1315 <br /> OWNER ADDRESS same CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump PHONE 466-9625 <br /> CONTRACTORADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95215 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 N C-61 ❑D-09 ❑Other NUMBER 724778 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE XYDomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If,litTuent from OwnWater yetem ame on— —c or Phom Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other 1_.. <br /> ❑Monitoring Well(s) #of wells Cl Soil Boring(s) 0 ofborings ❑Geotechnical s of borinp <br /> ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump M Pump Replacement ❑Pump Repair WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Peck/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement suck mix/7 gal water <br /> ❑Bentonite(200/solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length R Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 3XXSubmelsible ❑Turbine ❑Other HP 3 Pump Set 132 It Standing Water Level 65 it <br /> 1 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. 1 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 /> �MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TG/�/ 1 C i•%1L TITLE CEO DATE 08/14/06 <br /> .31 <br /> J UI <br /> i <br /> PARTMENT nErNL Y '-�I,ti•I <br /> Application Accepted By Date Area Employee ID# 9 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 101jo lee ❑ WAIVER Received <br /> Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received heck# Am at Date Permit/ Invoice# Well ID# <br /> Codes Info By ash Remitted Service Request# <br /> o c� S b 3 / <br /> EHD 43-02-oD6 WELL PUMP PERMIT <br /> 1/27/2005 <br />