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20846 <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 /> y <br /> JOBADDRESS 15771 R ST RT 88 CITY/ZIP LOCKEFORD, 95237 m <br /> D <br /> 0 <br /> CROSS STREET RT,T,T OT RD APN 019-17-025 PARCEL SIZE 5 3 . 7 1AND USE APPLICATION# <br /> m <br /> v, <br /> OWNER NAME L�OCKE RANCH ` PHONE 570-5272 <br /> OWNER ADDRESS PO BOX 31 2 /pU V v CITY/STATE/ZIP LOD I, 95241 <br /> CONTRACTOR Delta Pum _ WORKS IEAQ._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 ` <br /> LICENSE . ❑ C-57 K C-61 [ID-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 0 Domestic/Private R Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑ Public Water System <br /> IF different from Owner: Water System Name Gontact Name or Phone Number PA <br /> TYPE OF WORK ❑ New Well 0 Replacement Well 0 Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings 0 Geotechnical #orbarbB �Ve <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair YG <br /> ❑ New Pump ❑ Pump Replacement Pump Repair 0 Raise Well Casing 3 <br /> WELL CONSTRUCTION AN <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger 0 Cable Tool 0 Push Point 0 OtherENV/�QUIN CO <br /> Proposed Well Depth ft Excavation in diameter El Bottom D Gravel Pack/Gravel Size OEiRNbr <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft EN <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑ Neat Cement(941b bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersibleg Turbine 0 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 COMPENSATION LAWS. <br /> MINIM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE1 g 2 3 1 S— <br /> I <br /> OFWELL/PUMP IS LOCATED <br /> SIDE OF THE ROAD <br /> s <br /> DE ARTMENT USE O IL <br /> c / <br /> Application Accepted By Date C Area Employee ID#� <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By 6%0 Date ,\i+5 j i `b WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount 1Permit/ <br /> Codes Info B Date ash Remitted Service Request# Invoice# Well ID# <br /> w;' 316-13 ���2°I q� <br /> EHO 43-05 <br /> 8!04/08 <br /> WELL/PUMP PERMIT <br />