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Pf <br />19999 WELL/PUMP PERMIT <br />SAN410AQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />CALL (209) 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE[ <br />Amount <br />Remitted <br />u <br />Hll lr <br />Invoice # <br />Well ID# <br />JOB ADDRESS <br />24135 ST . <br />RT . 4 <br />CITY/ZIP FARMINGTON <br />95230 <br />CROSS STREET <br />STANLEY <br />APN 187-04-004 <br />PARCEL SIZE 6 0 <br />LAND USE APPLICATION # <br />OWNER NAME <br />TONY CHTAPPF/` <br />$ C <br />(�1)1a0De_ 4irm`7 <br />I/7L <br />PHONE 471 -5791 <br />OWNER ADDRESS5 <br />j 4 9 S. STANLEY RD.- <br />CITY/STATE/ZIP STOCKTON <br />CA 95215 <br />CONTRACTOR <br />Delta Pump_,qTnrKTnN <br />ARMAT1iRF <br />R MOTOR WORKS <br />iIAQ. 209-466-9625 <br />CONTRACTORADDRESS <br />646 S. <br />California Street <br />CITY/STATE/ZIP <br />Stockton, CA 95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 X C-61 ❑ D-09 0 Other. <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 724778 EXPIRATION DATE 08/t% <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ranae Secrinn <br />INTENDED USE Comestic/Private 0 Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. Water System Name ------(75rtact Name or Phone Number <br />i TeM Ur VVUKK a ivew vvett u Keptacement well ❑ Well Alteration/Modification <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s) <br />0 Out -Of -Service Well ❑ nut -Of -Service Well Renewal <br />❑ Other <br /># of borings ❑ Geotechnical <br />❑ Cross -Connection Repair <br />❑ Raise Well Casino <br /># of borings <br />WELL CONSTRUCTION N <br />Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel 0 Other <br />Grout Seat Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mixR gal water <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor C Other <br />C Concrete Pedestal Dimensions: Width It Length ft Thick in 0 Christy Box C Stove Pipe <br />PUMP IX,Xbmersible❑ Turbine ❑ Other HP _3_ 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVELITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. --'% <br />MINIMU)A_24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED��. /J i� 1/1 TITLE CED <br />DATE._1 2 10 4.117 <br />PUMP/WELL is located <br />approx. 54 ft. from drive <br />way <br />I <br />EW 4 <br />z oo - <br />CrnIt EP RTMENT U E ONLY <br />9v Z <br />o m <br />p p Pftion jte d By Date 7i Area 0 A 16'�C' Employee ID# <br />A Grout Inspection By Date ^� SPECIAL Well Permit <br />Pump Inspection By Date L� WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />IRV Cash <br />Amount <br />Remitted <br />Dat <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />.HD 43.06 <br />8/04/08 WELL /PUMP PERMIT <br />T <br />