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a <br />`20170 WELL/PUMP PERMIT P <br />SAN JOAQUIN 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 ISSUED <br />i <br />JOB ADDRESS <br />6150UPAMPY CRT. <br />CirY/ZIP STOCKTON 95215 <br />CROSS STREET <br />WHITE <br />APA( 101- 0 7-077 <br />PARCEL SIZE 2 . 3 <br />LAND USE APPLICATION # <br />OWNER NAME <br />GON ZAL04 CORTE Z <br />Ir <br />PHONL20 9 931 3413 <br />OWNER ADDRESS <br />SAME <br />CITY/STATE21P <br />CONTRACTOR <br />Delta PATmD--,qTnr-KTnN <br />ARMATiiRF R <br />MOTOR WORKS <br />II16a.209-466-9625 <br />CONTRACTORADDRESS 646 S. California Street <br />CITY/STATE/ZIP <br />Stockton, CA 95203 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS _ <br />LICENSE ❑ C-57 X C-61 <br />D D-09 D Other. <br />CITY/STATE/ZIP <br />NUMBER 724778 EXPIRATION DATE 08/ <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ranno -Q-44— <br />INTENDED <br />Q-44 ., <br />INTENDED USE 0)PAmestic/Private 0 Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />T,= Vr YYVKK L rtew vveii U Keplacement Well ❑ Well Alteration/Modification 0 Other <br />O Monitoring Well(s) # of wefts Q So(( Boring(s)# of borings Ofbonngs <br />0 Geotechnical <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal D Cross -Connection Repair ��� <br />0 New Pum m Re lacement 0 Pum Re air 0 Raise Well Casin <br />WELL CONSTRUCTION S® <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other r <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Graveld"Dw _ i aveter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ftF QU/ <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel 0 Plastic ❑ Stainless SteeN�ditjto NMN COUNo, <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack ater <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL installed By 0 Driller 0 Pump Contractor 0 Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersibleO Turbine 0 Other HP ---_3_ Pump Set ft Standing Water Level ft <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 <br />CURRENT AND ACTIVE THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSA ION LAWS. <br />MINIM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />JIGNED TITLE CEO <br />DATE 2/20/2018 <br />NOTE <br />PUMP SET & STANDING WATER LEVEL <br />IS UNKNOWN UNTIL THE JOB IS DONE <br />Application Accepted By G <br />Grout Inspection By <br />Pump Inspection By _ <br />Soil Boring Inspection By <br />COMMENTS <br />Codes i Info <br />Date <br />Date <br />Date <br />epth ft <br />:iw _:q <br />Employee I <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well D <br />Amount Date P' <br />2emitted Service <br />7� 122)I <br />#I Invoice # I Well ID# <br />EHD 43-06 <br />8/04108 WELL /PUMP PERMIT <br />T <br />m <br />g <br />M <br />m <br />Ul <br />