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19857 WELUPUMP PERMIT <br />•SAN JOAQUIN COUNTY ENviRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95206.6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 208 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />(JOS ADDRESS a n n >~ >;�r n m�' P CiTY/ZIP _STOC KION A 5 7 n If M <br />' a A <br />(CROSS STREET D ST. APN J_ 41 -1 5 - p 0 PARCEL SUE o <br />ll / ] 9 LAND USE APPLICATION # p <br />OWNERNAME MIZKAN PHONE209 304 0477 M <br />OWNER ADDRESS CITY/STATEiZiP <br />CONTRACTOR Delta P= cmnnxmnt'] A 2 12LlRF 4 MOTOR S40RKS x._209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITYiSTATElZiP Stockton, CA 95203 _ <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE 0 C-57 N C -G1 <br />C D-09 0 Other NUMBER <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />INTG7Jntn I lee <br />Y <br />CiTYiST ATE1Z\P <br />PHONE <br />EXPIRATION DATE 0 <br />Township Rancle Section <br />- .a« a nngaaonimgrlcuitural XKndustrial 0 Water Quality Monitoring 0 Soil Sampling/Characterizadon <br />0 Public Water System <br />If different from Owner: a er ys em ame <br />on a ame or one um er <br />TYPE OF WORK <br />C New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />G Monitoring WBff(s) # Of weffS C1 Soil Borings) # of borings <br />O # o(borings <br />C Our -Of -Service Well u Geotechnical <br />Out -Of -Service We)) Renewal 0 Cross -Connection Repair <br />New Pump C Pump Replacement Uump Repair <br />0 Raise Well C acinn <br />Drilling Method Mud Rotary Z Air Rotary 0 Auger - Cable Too) 0 Push Point 0 Othef <br />Proposed Well Depth ft Excavation <br />C Conductor Casing in diameter 0 Open Bottom <br />0 Gravel Pack/Gravel Size in diameter <br />in diameter i Conductor Casing Depth ft <br />Wel) Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depthft C Neat Cement (94 !b bag/5-10 gal 11 water) C SBentonite (2o% solids) 0 Other and Cement sack mixR gal water <br />Grout Placement Method 0 Pumped ❑ Free Fall 0 Other <br />0 Retardant /Accelerator (name) <br />PEDESTAL Installed By 0 Driller 3 Pump Contractor 0 Other <br />Concrete Pedestal Dimensions: Width <br />it Length g it Thick in 0 Christy Box 0 Stove Pipe <br />PUMP Submersible0 Wine C Other HPPum Set <br />ft <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THiS APPLICATION AND <br />T THE WORK WILL BEftDONE iNnACCORDANCE WITHg Water AN <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 />SIGNED MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE CEO DATE 9/22/17 <br />I <br />D€PARTMENT USE ONLY <br />Application Accepted 8y Date 1 <br />Grout Inspection By _ <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring inspection By <br />COMMENTS Date <br />u0cles_I Imfo <br />osc <br />EHD 43.06 <br />6!04!08 <br />Amount <br />----- Remitted�;rjl <br />2z <br />313D <br />Atea IbtL Employee )D# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />invoice # <br />ro <br />well ID# <br />WELL /PUMP PERMIT <br />HEALTH <br />"ES <br />