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20478 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 />.toe ADDRESS 9482.. c --ENDOW RLZ <br />CtTY/ZIP FR F:N(-H CAMP CA 25231 <br />CROss STREET 7F q T 4 1 P.P n APN 1 <br />A -j— 7 4— C) 6 4 <br />PARCEL 5.13 <br />SIZE LAND USE APPLICATION # <br />OWNER NAME 7ATMF DOMT C'n <br />PHONE406-4533 <br />OWNER ADDRESS P-0- BOX 808 T AHTRCPZ <br />7q <br />✓ l i <br />o2) � c,5`�C/STATE2P <br />A�C� <br />LA�pp 3-3 <br />CONTRACTOR Delta Pump <br />,qTnC'KTl7N <br />ARMATiTRF <br />& KS ff"Q. Q9-466-962 <br />CONTRACTOR ADDRESS 646 S. California Street <br />CITY/STATVZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />Crry/STATFJZIP <br />LICENSE 0 C-57 X C-61 ❑ D-09 0 Other <br />NUMBER 7247780g�_ <br />i:JCPIRATION DATE_ [t D <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />INTENDED USE RRomestic/Private G Irrigation/Agricultural ❑ Industrial <br />Township Range Section <br />0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner. <br />a er Ys em ame <br />—e -- <br />ac W-- or one Wu Te--, <br />TYPE OF—WORK ❑ New Well ❑ Replacement Well <br />❑ Well Alteration/Modification ❑ Other <br />C Monitoring Well(s) # of wefts <br />O Sof(Boring(s) <br /># Of bonnes # o/ borings <br />❑Geotechnical <br />C Out -Of -Service Well <br />0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />0 New Pum2 R)Fump Replacement <br />HELL CONSTRUCTION <br />0 Pum Repair <br />D Raise Well Casin q <br />(Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other Vt <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in ArriZbi <br />0 Conductor Casing in diameter / Conductor Casing Depth ft -:'�SOA <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched QU/N <br />0 Steel ❑ Plastic ❑ Stainless Steel 0 Cb1?'jq 0Ny CO <br />Grout Seat Depth tl 0� Neat Cement (94 Ib bag/5-10 gal water) <br />8� <br />0 Sand Cement sack mix T <br />❑Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall ❑ Other <br />❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in 0 Christy Box 0 Stove Pipe <br />PUMP ubmersible0 Turbine 0 Other <br />HP --j Pump Set ft Standing Water Level R <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />WORKERS COMPENSA !ON 1 a c <br />CURRENT <br />STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE CEO DATE <br />NOTE <br />PUMP SET & STANDING WATER LEVEL <br />IS UNKNOWN UNTIL THE JOB IS DONE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Codes <br />EHD 43-06 <br />8/04/08 <br />Info <br />Amount <br />Date <br />Date <br />Date <br />Date <br />Date <br />Area ((:'I / Wim_ Employee ID#izdz <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />L, <br /># I Invoice # <br />Well 1D# <br />WELL /PUMP PERMIT <br />0 <br />