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" 19466 0 <br /> 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 RT. 4 CITY/ZIP FARMI NGTON 9 5 2 3 0 m <br /> Q — D <br /> CROSS STREET STANLEY RD. APN 1 R 7—0 4—0 2orw PARCEL slzE1Q_LAND USE APPLICATION# <br /> OWNER NAME TIMY CHIAPPE 1 Aj 4Vto6q Carle J 1 r- t 44m PHONE 2 0 9 d 1 -5 7 91 <br /> OWNER ADDRESS 5419 k. STANLEY RD. CITY/STATEIZIP STOCKTON 95215 <br /> CONTRACTOR Delta Pump QTnCKTnN ARMATilRF' & MOTOR WOj�KB t►Pd ISS. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> IIISUBCONTRACTOR _ PHONE <br /> 1SV8COf{TftACSOR ADDRESS CITY/STATEIZIP <br /> (LICENSE 11 C-57 X C-61 0 D-09 C Other NUMBER 724778 EXPIRATIONDATE 08/11 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private !XKigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: a er ys em1,4ame Contact Name or one Num or <br /> TYPE OF WORK C New Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other <br /> G Monitoring Wells) #of wefts C Soil Boring(s) a o <br /> s #of borings f <br /> G Geotechnical gFr�ED <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑ New Pum2 ❑ Pump Replacement pCEUmp Repair 0 Raise Well Casin <br /> WELL CONSTRUCTION <br /> jy Jo <br /> Drilling Method C Mud Rotary 0 Air Rotary 0 Auger 01 Cable Tool 0 Push Point 0 Other �E1MRo UI N caur,ry <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size �iri°�alffater <br /> C Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other I( <br /> Grout Seal Depthft 0 Neat Cement(94 lb bag/5-70 gal water) ❑ Sand Cement sack mix/7 gal water j <br /> 0 Bentonite(20%solids) O Other <br /> Grout Placement Method 0 Pumped 0 Free Fall u Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller D Pump Contractor 0 Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe­i <br /> PUMP 00 Submersible rbine ❑ Other <br /> 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSAT(Qpl <br /> MINIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 5/16/2017 <br /> 1 - <br /> 1A MS <br /> �. PUMP/WELL is located <br /> • � � �� between the shack and the <br /> Shack �" plowed field. <br /> PE <br /> Mobile home <br /> Mrd: <br /> NOTE: <br /> PUMP SET&STANDING WATER LEVEL <br /> IS UNKNOWN UNTIL THE JOB IS DONE <br /> DE ARTMENT U E ONLY <br /> Application Accepted 8y �/V ' <br /> ion By Date <br /> Grout inspectDate �q� <br /> 4145l� Date / Area <br /> ��`t'�--�--- Employee iD#.� 17 <br /> Pump Inspection By 1� SPECIAL Well Permit <br /> �� p <br /> Soil Boring Inspection By Date WAIVER Received <br /> COMMENTS Constructed Well Depth ft <br /> PE Sc Received Amount <br /> Codes Info B Cash DPermit/ <br /> Remitted ate Service Re uest# Invoice# <br /> :;,,n Wel!ID# <br /> !Jv �' J <br /> EHD 43.06 <br /> 8104/08 <br /> WELL/PUMP PERMIT <br />