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20336 WELL/PUMP 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 />JOB ADDRESS�a -kl,_ LINNAE RD CtTY/ZIP TRACE' CA 25304 m <br />D <br />CROSS STREET I — 5 APN % — 2 — Q (a PARCEL SIZE 5 0 - 4 NAND USE APPLICATION # C, <br />OWNER NAME PHONE 209 499 6209 `r <br />OWNER ADDRESS 3828 AMB Rn S TA T ANF CITY/STATE/ZIP_MODE S TO CA 95356 <br />CONTRACTOR Delta Pump STACKTON ARMATURE & MOTOR WORKS 11116Q...209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STA7E/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/S7A7E/ZIP <br />LICENSE ❑ C-57 X C-61 D D-09 0 Other NUMBER 724778 EXPIRATION DATE 08/ft <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />vvine�ucrrnvafe L ITgation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 11 Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner: Water bYslern Name 'UMUCL Name or one Number <br />1 YPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />G Monitoring Welf(s) # of Weffs C So(( Boring(s)# of ba borings <br />odngs D Geotechnical <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Uew Pump 0 Pump Replacement 0 Pump Repair <br />Al"D Raise Well Casinr <br />Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom D 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 0 Steel D Plastic Cl Stainless Steel 0 Other <br />Grout Seal Depth ft C2 Neat Cement (94 Ib bag/5-1Q gal Water) 0 Sand Cement <br />o sack mixR gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />Dr <br />oy a Ulmer a rump Contractor ❑ Other <br />f C Concrete Pedestal Dimensions: Width ft Length ft Thick to 0 Christy Box ❑ Stove Pipe <br />PUMP 0 Submersible❑;5�rbine ❑ Other HPPurn Set <br />� H P ft Standing Water Level R <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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION 4h1Aifi 1 <br />SIGNED <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE CEO <br />DATE EZ2 /201,9 <br />RTMENT US <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection <br />Inspection <br />ti <br />Soil Boring t pection By <br />COMMENTS <br />PE SC <br />Codes Info <br />3dS4�3 <br />EHD 43-06 <br />8/04/08 <br />Date <br />Date <br />Date <br />Date <br />Date <br />Ser <br />Area Employee ID#� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />nest # Invoice # Wel! ID# <br />X21 �- <br />WELL /PUMP PERMIT <br />