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f 1 91` 5 4 -T�'q%o.� �I C c, r .�1-17 C� , � �. WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NUN-KEFUNDABLE PERMIT (;ALL LUy y -'53-1b9_[ FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 6 4 9 85MOBLEY RD- CITYIzIP STOCKTON 95215 CROSS STREET VAL ALLEN APN 1 R 5 -1 �e� PARCEL SIZE 1 . 0 1 LAND USE APPLICATION # r OWNER NAME JANET RATES PHONE 2()C) 9 R S —1 82 0 OWNER ADDRESS SAME CITY/STATEIZIP STOCKTON CA 95215 CONTRACTOR Delta Pump _,qTnf KTnN ARMAT tRF & MOTOR WORKS 1MGh._209-466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE ❑ C-57 X C-61 ❑ D-09 ❑ Other, PHONE CITY/STATE/ZIP NUMBER 724778 EXPIRATION DATE -08/1'1 GEOGRAPHICAL INFORMATION: Coordinates X Y Tnwnahin P—m. ce..Fi__ INTENDED USE XX Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization O Public Water System If different from Owner: Water System Name _______C_0_nFaCt Name or Phone Number 1 YPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other 0 Monitoring Well(s) # of wells D Soil Sorin9(1 ❑Geotechnical s # of borings # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pump CyRump Replacement 0 Pump Repair ❑ Raise Well Casino Drilling Method ❑ Mud Rotary ❑ Air Rotary C Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter C Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTM Sched O Steel ❑ Plastic ❑ Stainless Steel D Other Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mixl7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method C Pumped ❑ Free Fall ❑ Other n Ratnrrlant / Arr.1—tnr r- 1 PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other 11 Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP XX7 Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE CEO DATE -31712()17 n.7 i m D 0 0 M m N VES ?017 - HEALTH ICES 'IFN l�Fr 201, 4; !ti Area__y �Employee ID#—� VW SPECIAL Well Permit WAIVER Received Constructed Well Depth ft PE Codes R T M E N T USE N LY Application Accepted By z= VV1WY��=�1/��A Date 7/ l Grout Inspection By Date Pump Inspection By _� Date Soil Boring Inspection By Date COMMENTS n.7 i m D 0 0 M m N VES ?017 - HEALTH ICES 'IFN l�Fr 201, 4; !ti Area__y �Employee ID#—� VW SPECIAL Well Permit WAIVER Received Constructed Well Depth ft PE Codes SC Info Received B Cash Amount Remitted Date Permit/ Service Re nest # Invoice # Well ID# SK007707q W0o3 U!Zcum 8/04/08 VV WELL /PUMP PERMIT