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20381 WELL/PUMP PERMIT <br /> 43AN 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 /> N <br /> Joe ADDRESS 1010 E. MADR UGA RD. ' CITY/ztP LATHROPk CA 95330 ern <br /> CROSS STREET GUTHM I LLER RD.Apfv 2 41 -41 -0 0 6 PARCEL SIZE 6 - 6 2 LAND USE APPLICATION# G <br /> M <br /> OWNER NAME � PHONE <br /> 2-09 Q 7_ A ti q <br /> OWNER ADDRESS P.O CITY/S TE21P R FN <br /> CH VAMP 9 5223 <br /> CONTRACTOR Delta Pump .STOCKTf�N ARMATLlRF & MOTOR WORKS ff"1Q 209-466-9FL25 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE ❑ C-57 X C-61 0 D-09 ❑ Other NUMBER 724778 EXP(RATIoN DATE 08/ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township Range Section <br /> INTENDED USE 0.Domestic/Private Dl Mgation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner, a er ys em Name Contact Name or one Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Wells) #of welts 0 Soif Boring( )s #of borings ❑ Geotechnical <br /> #of borings <br /> ¢Iut-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement O.Pump Repair ❑ Raise Wall Casin <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation— <br /> in diameter 0 Open Bottom 0 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 ❑ Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement <br /> sack mixR gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor 0 Other <br /> C Concrete Pedesta)Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible0bine 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT J AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M1NtMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO <br /> DATE 5/14/2018 <br /> R <br /> PUMP/WELL is located past I ,' <br /> the small house along the <br /> 1�f P k <br /> 1 1 f <br /> Guthmiller Rd. <br /> s: <br /> w <br /> t. <br /> � A � <br /> E A � <br /> P <br /> ..., .... a.. ..,sr .. ... ..,.,,�.+i._.,ti <br /> EP RTMENT U E NLY <br /> Application Accepted By Date <br /> Date <br /> Area Employee ID# <br /> Grout Inspection By <br /> SPECIAL ell Permit <br /> Pump Inspection By. <br /> Soil Boring Inspection By Date WAIVER Received <br /> COMMENTS L _ Date Constructed Well Depth ft <br /> �S� c r y c <br /> PE SC Received ec <br /> Codes Info g Amount Date Permit! <br /> ash Remitted Service Re uest# Invoice# Well ID# <br /> EHD 43-06 <br /> 6104/08 <br /> WELL/PUMP PERMIT <br />