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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMZNT #12568 600 E.Main Street-STOCKTON CA 95202 -(209)468)420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPMES I YEAR FROM DATE ISSUED <br /> I � <br /> i JOB ADDRESS 24465 E. Highway 4 CITY/ZIP Farmington 95230 i <br /> Ig <br /> CROSS STREET Jack Tone Road "N 187-040-29 PARCtLS¢a: 7'?S LANDUSCAPrucATIONN V <br /> OWNER NAME .Herman Boone PHONE 886-5553 <br /> OWNER ADDRESS same, C MISTATVZIP <br /> CONTRACTOR Delta Pump PHONE 299-466-96.25 <br /> CONTRACTOR ADDRESS 646 S. California Street CrrY1STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C17YISTATVZFP <br /> LICENSE ❑C-57 XXC-61 0 D-09 ❑Other NvmEA 724778 EXPIRATION DATE 08/12,- <br /> i <br /> CEOGRAPnICALINTOkmATION: Coordinates X Y Towofblp Rangt Section ' <br /> i <br /> II INTENDED[ISE ]30omestic/Private 0Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization i <br /> ❑Public Watcr System <br /> If d Hertnt Som Owner. Wta syue.Nsme CML40 Nuse of rb=e <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Altcration/Modification ❑Otho <br /> ❑Monitoring Well(s) p of welts ❑Soil Boring(a) a of bono4s ❑Oeotechnicid. sof Boriagr <br /> ❑Out-0f-Service Well 0 Out-0f-ServMe Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump XMIump Replacement ❑Pump Repair <br /> W ELL CONSTEUaTO w <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger Q Cubic Tool 0 Push Point ❑Other <br /> Proposed Well Depth it Excavation in diameter ❑Open Bottom 0 Gravel Pack/Gravel SiZA ' In dlamcwr l <br /> 0 Conductor Cuing . in diametet / Condutt6r Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schod '- - ❑Steel ❑Plastic '[3 Stainless Steel Cl Other <br /> Grout Sed. Depth ft O Nut Coment(p416 bag/J-10 gal water) 0 Sand Cement tack mU/7 gal water ��.. <br /> ❑Bentonite(2094 solids) -❑Manufacturer Spec Y solids_% Name ❑Specs on File ❑Specs Submitted S <br /> Groat Placement Metbod ❑Pumped 0 Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> P�PFdTelr Installed By ❑Driller 0 Pump Contrador ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length R Thick in ❑Christy Bos ❑Stove Pipe <br /> X&Submersible ❑Turbine LJ Other HP 5 Pump Sat R Standing Water Lovo1 H <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. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP€A79KrW LA <br /> �'[NII�IMU 24 I-F46LVRADVANCCE N'TICE RE DF INSPEC IONS i <br /> S[CNED <br /> TITLE CEO DATE <br /> i <br /> Lh <br /> zz <br /> o S <br /> i <br /> yr O Ity <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date t7 1� �DArea Employee IDI! <br /> Grout Inspection Dy — Date 13 SPECIAL Well Permit <br /> Pump Inapcdion B — Date_L�f) ❑ WAIVER Received <br /> Constructed Well Deptb Jt . <br /> COMMENTS <br /> PE SC Recelvtd les Amount Date Permit/ Invoice N Well and <br /> Codes Info By Cash Remitted Service Re ucstN <br /> 3�( L a S 53.0-0 t v ,moo ;2,7-2 �� 1 <br />