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20617 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT <br />WELL/PUMP PERMIT <br />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 5090 E MORADA LANE CITY/ZIP STOCKTON 95212 <br />CROSS STREET H T (-KC)R Y T,A NF. APN QRS -1 7-00'3 PARCEL SIZE 1 _ 0 LAND USE APPLICATION # <br />OWNER NAME RARRRA FRINC'TS PHONE 915-7965 <br />OWNER ADDRESS q A MF. CITY/STATEIZP <br />CONTRACTOR Delta Pump _STnCxTc)N ARMATURF & MOTOR WORKS f"&_ 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEMP 1Q <br />LICENSE 0 C-57 X C-61 0 D-09 ❑ Other NUMBER 724778 EXPIRATIONDATE 08/1 p <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rance Sar_linn <br />INTENDED USE ADomestic/Private C Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring O 'Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner: WaterSystern Name Contact Name or Phone Number <br />I YPE OF WORK G New Well ❑ Replacement Well <br />❑ Well Alteration/Modification <br />❑ Other <br />D Monitoring Wells) # of wells <br />0 Soil Soring() s <br /># of borings <br />❑Geotechnical <br />r s <br />C. Out -Of -Service Well <br />❑ Out -Of -Service Well Renewal <br />❑ Cross -Connection Repair <br />C New Pump R Pump Replacement <br />0 Pump Repair <br />❑ Raise Well Casino <br />E�:FIIi� <br />Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other Ayy 3 �n�n <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel �J In diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft /i '-"nUN1HENTUNIY <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched D Steel 0 Plastic 0 Stainless Steel 0 O EP '` - <br />Grout Seat Depth ft ❑ Neat Cement (94 lb bag/5-10 gai water) 0 Sand Cement sack mix/7 ga ater <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP ubmersibleO Turbine 0 Other HP 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 ACTZIVE W CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSAT ON LAWS. <br />MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CED <br />DATE'Z/ 7 4 12ni R <br />PUMP/WELL is located <br />behind the garage next <br />to the house, under the <br />trees. <br />• `� is P- <br />� � , et <br />y <br />P RTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID#�- <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />d/U9/O8 WELL !PUMP PERMIT <br />T <br />1 <br />m <br />D <br />Q <br />a <br />m <br />m <br />�F <br />