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�)1 i,; /q- <br />WELUPLIMP PERMIT <br />SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 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 />IJOB ADDRESS —44-921 821 SAT PT('.(] &A CIrY/ZIPTRACY 95376 I m <br />CROSSSTREET__.. Cl7R R A T unr T pW APN_ 242 Q D D 6 PARCEL SIZE USE APPLlCAT10N # o <br />OWNER NAME GORDON �MOSBY <br />PHoNF925-383-6343 <br />OWNER ADDRESS __SAME CITY/STATE/ZIP <br />CONTRACTOR Delta Pumy STOCKTON ARIVILTURR oy M TnP WORKS .�09-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton CA 95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE O C-57 X C-61 0 D-09 0 <br />PHONE <br />CITYfSTATEJZIP <br />NUMBER %24778 EXPIRATIONDATE_ 08/17 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Township Range Section <br />INTENDED USE Cl A stic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 uXblic Water System <br />If different from Owner. Water System Name <br />U -MM Name or Phone Number <br />TYPE OF WORK 0 New Weil 0 Replacement Well 0 Well Alteration/Modification <br />Monitoring Welf(s) # ofwells L So// Boring(s) <br />Out-Of-Service Well 0 Out -Of -Service Well Renewal <br />0 Other <br /># of borings <br />G Geotechnical <br />0 Cross -Connection Repair <br />0 Raise Well Casino <br /># of borings <br />Drilling Method C Mud Rotary Air Rotary 0 Auger ? Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) C Sand Cement <br />l Bentonite (20% solids) '7 Other sack mizl7 gal water <br />Grout Placement Method 0 Pumped El Free Fail C Other <br />0 Retardant /Accelerator (name) <br />PEDESTAL Installed By 0 Driller G Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in G Christy Box G Stove —Pi.. <br />Lj�xbmersibleO Turbine C Other HP 1 Pump Set <br />1 HEREBY CERTIFY THAT i ft Standing Water Level (t <br />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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSA7'I0ZW. Vj&;--__ <br />HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE CEO <br />NOTE: <br />PUMP SET & STANDING WATER LEVEL <br />IS UNKNOWN UNTIL THE JOB IS DONE <br />APPllcation Accepted Sy <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Co <br />EHO 43.06 <br />8104108 <br />Info <br />Amount <br />Date <br />Date <br />Date <br />Date <br />DATE 7/ 13 /2017 <br />Area Employee [DO oG03 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />ltir4l;:�lp� _7 <br /># I Invoice # <br />Weil ID# <br />WELL /PUMP PERMIT <br />