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0? ) <br /> WELL rP9JI1 P PERMIT <br /> SAN JOAQUIN COUNTY L-NVIRON6IEN T AL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-RE=FUNDABLE PERMIT CALL(209)953-7697 Fol:ItiSFLC iEXPIRES 1 YEAR FROM DATE ISSUED <br /> n ///I Zi <br /> m <br /> Jos ADDRESS ' / 7 S, Au�T l/1 f d CITY/ZIP �C�C f� e C u`. D <br /> CROSS STREET FE Q►I)r Ayc- APN elC_ y-e2n- y oZOPARCEL Slzk �AND USE APPLICATION fF <br /> OWNER NAME r 'C 1 ` Vo.-, PHONE 46 9 <br /> OWNER ADDRESS =moi �s CITY/STATE/ZIP <br /> CONTRACTOR Delta 1211(ua iI1C: PHONE (209) 466-9629 <br /> CONTRACTOR ADDRESS 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACToK PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE . C-57 )(C-6'i D-09 E Other NUMBER 1055434 EXPIRATION DATE 8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ,<bornestic/Private Irrigation/Agricultural = Industrial 't.. Water Quality Monitoring : Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: ater ystam Nanne Uoniact Name or Hhono urncer <br /> TYPE OF WORK ❑ New Well _ Replacement Well D Well Alteration/Modification ❑ Other <br /> D Monitoring Well(s) #of wells -- Soil Boring(s) of borings D Geotechnical <br /> ref <br /> AL <br /> ❑ Out-Of-Service Well . out-Of-Service Well Renewal ❑ Cross-Connection Repair �� � '�' <br /> D New Pum um Replacement C Pum Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION NOV9 <br /> Drilling Method E Mud Rotary E Air Rotary E Auger C Cable Tool D Push Point II Other N ! 4 7n!n <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom u Gravel Pack/Gravel in diameter <br /> W <br /> Conductor Casing in diameter / Conductor Casing Depth ft H�gE' <br /> NNVI � �, <br /> TUNell Casing Diameter_ in Thickness/Gauge/ASTM Sched D Steel D Plastic D Stainless Steel C. 04"PE AL <br /> Grout Scat Depth ft E Neat Cement(94 Ib bag15-10 gal water) I Sand Cement sack mix/7 ga aWr <br /> 1 Bentonite(20%solids) E Other <br /> Grout Placement Method ❑ Pumped I: Free Fall i-: Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor L Other <br /> L Concrete Pedestal Dimensions:Width ft Length It Thick in Christy Box E Stove Pipe <br /> PUMP Gj�� E Subm rsibI,,XTurbine -. Other _ HP Pump Set ft Standing Water Level ft <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 COPA _N -ON LAWS. <br /> CA <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS /+ I <br /> SIGNED v'r/ TITLE CEO DATE /- <br /> ' r <br /> I A-Q <br /> _ - .ECJ -�3yc���+i �"'u�p•�7` `7 .. - ` <br /> 0j <br /> DEPA TMENT USE ONLY <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By %�:_`j1�1C'- �� 'r y, Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> DWY <br /> EHD 43.Ou <br /> 670:108 WELL/PUMP PERMIT <br />