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JOB ADDRESS 4799 N JACKTONE RD. <br />FATRCHTT,T) RD_ CROSS STREET <br />PHoNE209 986 2808 <br />OWNER NAME cFunlo-i-roLn STEMTT,T <br />4799 N. JACTONE RD. OWNER ADDRESS <br />crryizIRSTOCKTON 9521 5 <br />APN DP/ - (11 I PARCEL SIZE1 2. 8 7 LAND USE APPLICATION # <br />crryisTATEiztpSTOCKTON 952 1 5 <br />ARMATT/RF & MOTOR WORKS arbia. 209-466-9625 <br />California Street CITY/STATE/ZIP Stockton, CA 95203 <br />PHONE <br />CITY /ST ATE/ZIP <br />LICENSE 0 C-57 X 0-61 0 D-09 0 Other NUMBER 7 24 7 78 EXPIRATION DATE 0 8/ ill <br />CONTRACTOR Delta Pump —STOCK TnN <br />CONTRACTOR ADDRESS 646 S. <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE CEO DA <br />NIMUM 24 <br />SIGNE^ <br />PUMP/WELL is located <br />approx. 181.5 from the rod <br />1.1 <br />e <br /> <br />Grout Inspection By <br /> <br />Pump Inspection By '---- Carr/ fli; <br /> <br />Soil Boring Inspection By <br />COMMENTS To ifY1 (4 C. 5c4 d W <br />\c-\ \<-> <br />Area ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />1 <br />ate -• <br />Date <br />Date <br />Date <br />ESe"ci- c- <br />ft <br />• <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT <br />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 /> Township Range Section <br />Domestic/Private IXXrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: WaTeTST/TfTr—Nn ame Contact Name or /-'hone Number <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />INTENDED USE :SSaNCIOV 311S TYPE OF WORK 0 New Well 0 Replacement Well <br />0 Well Alteration/Modification <br />)(jOut-Of-Service Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well Renewal <br />0 Soll Boring(s) <br />11 New Pump 0 Pump Replacement O Pump Repair <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger U Cable Tool <br />ther <br />uuringS <br />u kJeotechnical <br />Cross-Connection Repair <br />CI Raise Well Casing <br /># of borings <br />0 Push Point 0 Other <br />Proposed Well Depth <br />Well Casing <br />Grout Seal <br />ft Excavation in diameter 0 Open Bottom <br />Conductor Casing In diameter / Conductor Casing Depth <br />Diameter in ThIckness/Gauge/ASTM Sched 0 Steel <br />Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) <br />Bentonite (20% solids) CI Other <br />0 Gravel Pack/Gravel Size <br />ft <br />in diameter <br />0 Stainless Steel 0 Other <br /> sack mix/7 gal water <br />Plastic <br />Sand Cement <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller E Pump Contractor 0 Other <br />Concrete Pedestal Dimensions: VVIdth ft Length _ _ it Thick in L) Christy Box 0 Stove Pipe <br />PUMP E SubmersibleUurbine Ii Other HP 40 Pump Set /6 a ft Standing Water Level <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 CURRENT AND ACTIVE WITH THE •NIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />.g a s h i Amount <br />Remitted Date Permit/ <br />Service Re,. uest # <br />. r t... tt_rv ..., . <br />Invoice # Well IDff <br />ps els 6 ,g ))- - q 11c- wro6 2)--7i <br />AYIVIENT <br />RECEIVED <br />ENDA:I-0R <br />8/04/08 <br />SEP 15 2017 WELL /PUMP PERMIT <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT