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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DEPARTMENT #10371 600 E.Main Street-STQCYTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE LSSUED <br /> JOB ADDRESS 408 N. Bern Road y Cm/z)mjT Stockton 95215 <br /> CROM STujuzT Copperoaolis APN 103-040-,87 PARCEL SIU LArm Use AlmucwAonY <br /> OWNER NAM Ken Merrihew pRoNg 408-739-5360 <br /> Ow AD aucu$ 1635 Manitoba DriVe CrTv/SrATvw Sunnyvale. CA 94087 <br /> CorrnsAcron Delta Pump Paox1209-466-9625 <br /> CONrMCIOR ADDR,en 646 S. California Street Crit/SFATE(LV Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SOBCONTRACTORADDRLSS LTTYSMErLIP <br /> UCENse E3 C-57 %ZC-61 0D-09 ❑Omer NUAmu 724778 EA HIATION DATE 08/10 <br /> GeOGRAPmGV.IXEORMATIQN: Coordinates Jt Y Towoabip_ Range_ Seedoo_ <br /> INTENDEDUSe ❑Domeaicli'dvale 'gadon/Agriculhual ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chaneteriatun <br /> ❑Public Wamr Syys5ttem — - - — — - <br /> IramejaemOxea: W.syjsnac ane .Nsuscorpoos'Nmmw <br /> Tyre OE WORK ❑New Well ❑Replacement Well ❑Well Alteratiormdifiution 13 Other <br /> ❑Monitoring Woll(s)_0 ofw.11s ❑Soil Baring(,) 0 afbamyr ❑Geotahnical a oebenep <br /> ❑Out-Of-servia Well ❑OmofSmke well Renewal ❑Cross-Cormecdon Repair <br /> ❑New Pam ❑Pump Replacement Uftmp Repair <br /> WEr L CONSTRUMON <br /> DnIllog Method ❑Mud Rotary ❑Air Rotary ❑Auger ID Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth B Exuvetion in dWnemr ❑Open Bottom ❑Grant Pack/Gravel Stu In diameter <br /> ❑CeoduaorCuing tndiamemr / Conducmr Cuing Depth B <br /> Well Cuing Dmmmer_u Thiclm.s/GaugdASTMSched ❑Sial OPluda 13 Stainless Steel 13 Other <br /> Groul Seal Depth B ❑Neat Cement(9/lb bag/L/0ga/warn) ❑Sand Cement sank nit/7 gal wamr <br /> ❑Benuoite(20%solids) ❑Manufaluur Spee%solid,_% Name ❑Speoson File ❑Specs Submitted <br /> Grosl Placement Method ❑Pumped ❑Free Fall Cl other ❑Remrdam/Accelentor(sems) <br /> l:.EPXTfAL [mtaBed By ❑Driller ❑Pump Contractor (3other <br /> ❑Cddercte Pedestal Dimensions:Width B Length RThick in Ochil, Box ❑Stovepipe <br /> 172¢ ❑SubmersUle.3`YTurbue ❑Other F{P 60 Pump Sm 160 BSunding Water Lavel 2 R <br /> 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM DI COMPLIANCE WITH ALL <br /> WORIS RS COMPEN, dWS. __ _ __ <br /> ~MINIM 24 HfODUi AA VANCE NOTICE REQUIRED FOR INSPECTIONS <br /> STGNEB �/v/ Tnu CEO DATE 05/19/09 <br /> IL <br /> �jf�� PARTM ENT USE ONLY <br /> Application Aceepladlly,_!-2 l EDate Area Bmploya f,a <br /> Grout Inspection By Dam ❑ SPECULWellPermit PAYMENT <br /> Pump Inspection ByDMe 6���09 ❑ WArVERReceived RECEIVED <br /> Constructed Well Depth It <br /> COMMENTS ae�- <br /> 7,96 6?ii sjadeMa tnNe� Tf <br /> PE SIC (Cbecw Amount Date Parm iF Iaeeiee0 HFJWFH' � <br /> Cod. lard B h Rembnas! Servlet Re anit0 <br /> V) B 3USct3 <br />