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2C`246 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDREss 21831 N. HWY 99 FRONTAC,F. gr) CITY21P_ACAMPO 94220 <br />CROSS STREET BTWN PELT I ER & ACA>MP0 013-19-033 PARCEL SIZE 59, O&ND USE APPLICATION # <br />OWNERNAME PEIRANO RSTATR WTNFR:�; -a C1 Y) CC�ol,11, PHONE <br />OWNER ADDRESS SAME <br />CITY/STATE/ZIP <br />CONTRACTOR Delta PumD_STr)rKTnN ARMAT IR . & MOTOR WORKS IIrYdQ. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 1�r <br />LICENSE ❑ C-57 X C-61 ❑ D-09 0 Other NUMBER 724778 EXPIRATION DATE 081 p <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ranae Section <br />INTENDED USE 0 Domestic/Private XXrigation/Agricultural 0 Industrial 0 Water Quality Monitoring O Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner. Water System Name Conlact Name or Phone Number <br />T rC Vr rrvKr, a rvew vveu u Keplacement well ❑ Well Alteration/Modification 0 Other <br />O Monitoring Wells) # of wetfs O Soft Boring(s)# of borings # of borings <br />❑Geotechnical <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair w�■� <br />0 New Pump 0 Pump Replacement X1�pAft <br />ump Repair ❑ Raise Well Casino _ A ki-ft <br />Drilling 4 P4 �ir rCg Method ❑Mud Rotary 0 Air Rotary ❑Auger ❑Cable Tool D Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size F/ dr <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched0 Steel o Plastic ❑ Stainless Steel l��IbfO�AQV/N COtf►,,. _ <br />Grout Seat Depth ft 0 Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement �lld9 ater <br />0 Bentonite (20% solids) ❑ Other ENT <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL installed By ❑ Driller 0 Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Lenat <br />tt Thick in ❑ Christy Box ❑ Stove <br />PUMP ❑ Submersible bine ❑ Other HP Pump Set ft 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 COMPENS'� <br />MINIMUJd124 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO DATE <br />IVUit <br />PUMP SET & STANDING WATER LEVEL <br />IS UNKNOWN UNTIL THE JOB IS DONE <br />DEPARTMENT USE ONLY <br />Application Accepted By�1411� Date 2-- Area Employee [D#— <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date qtibr WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />PE SC Recei <br />Codes Info I BY <br />la 3Y, OS v GG�rQ <br />Date <br />Constructed Well Depth <br />Remitted Date rarrmv invoice # <br />Service Re uest # <br />307 y/2,y1- <br />ft <br />EMD 4386 <br />8/04108 WELL /PUMP PERMIT <br />m <br />g <br />m <br />