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20837 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT (:ALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Job ADDRESS 24243 N RGND RD CITY/ZIP --LeE)i95242 <br />CROSS STREET pELTI ER APN 011- 0 5-008 PARCEL SI?E2 A 7 214AND USE APPLICATION # <br />OWNER NAME DESNAVER DAIRY PHONE <br />OWNER ADDRESS SAME CITY/STATE/ZIP <br />CONTRACTOR Delta Pump _ _TnrKTnN ARMATLiRE & MOTOR WORKS EAQ. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE . ❑ C-57 X C-61 ❑ D-09 ❑ Other <br />GEOGRAPHICAL INFORMATION: Cooirdinates X <br />Y <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 724778 ExPiRATIONDATE 08/1q <br />Townshin Ranap .Rnrrinn <br />INTENDED USE ❑ Domestic/Private � Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑Soil Boring # of borings <br />Boring(s) ❑Geotechnical VIA <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair REFCe,vF <br />❑ New Pump ❑ Pump ReplacementPump Repair ❑ Raise Well CasingYC <br />WELL CONSTRUCTION XP C� <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other l• O 21 9 <br />pq <br />8 <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Siz OA(JnCi1� peter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft HEALTHD,, MENTAL Y <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other EpARTIyENT <br />Grout Seal Depth ft ❑ Neat Cement (941b bag/5-10 gal water) ❑ Sand Cement sack mix(7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor O Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP 1k Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Leve ft <br />I HEREBY CERTIFY THAT 1 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 LAWS. <br />INIM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO <br />DATE 10/2318 <br />DE ARTMENT USE ONLY <br />Application Accepted By4*WA Date4-w//r <br />Grout Inspection By Date <br />Pump Inspection By Wb"t kb Date _l 1313 j, 107 <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area <br />Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/Invoice <br />Service Request # <br /># <br />Well ID# <br />05� <br />� 113 <br />to <br />MR60,1 4 7 <br />env 43-06 <br />8/04/08 WELL /PUMP PERMIT <br />T <br />m <br />D <br />0 <br />0 <br />X <br />m <br />H <br />to <br />