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181QIp,I. WELL/PUMP PERMIT <br /> SANJOAQUINCOUNT(ENWRONMEMA�!!!!lIMMMHHHEALTH DEPT 1868 East Hazelton Avenue-STOoxmON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT MH CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> Joe ADDRESS 9355 4 -W' C"rzjp STOCKTON 95206 "mD <br /> CROSSSTREET- S. INLAND DR. APN 131-09-021 PARCEL SIZEl .52 LlWO USEAPPLICATIONN z <br /> OWNER NAME PETF:`$ PLACF. PHONE 209 962-2976 I " <br /> OWNER ADDRESS SAME CITY/STATE/ZIP <br /> CONTRACTOR Delta Ptuarl—QT0r4(TONt ARMATURE R MOTOR WORKS 115160. 209-466-9625 <br /> CONTRACTORADomiss 646 S. California Street CIT'/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATE/ZIP <br /> LICENSE O C-57 K C-61 O D-09 0 Other Numaea 724778 EXPIRATION DATE 08/16 <br /> GEOGRAPHICALINFORMAMON: Coor" t.3X Y P) TOwnshlp_ Range_ Section_ <br /> INTENDED USE gf�OlnestldPdvatG'10 InigatloNAgdcullursl 0 Induskel IQ Water Quality Monitoring D Soo Sampling/Characterization <br /> 0 Public Water System I' <br /> If GXlanntfmm Ovmu: r Ys m em ams or ar <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Afterslion/ModlRcadon 0 Other <br /> 0 Monitoring Well(s) flofwelle O Soil BOdn x asors0 <br /> t" nes <br /> BO s ❑Geotechnical col earl <br /> 0 out-OFServICe Well 0 Out-Ofsarvice Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 PUMP Re lacament k%m2 Re alr 0 Rause Well Casing <br /> WELL CONSTRUCTION yC <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑® 0 Other fgtc R' <br /> Proposed Well Depth ft Excavation Ilnyc lS�p 9 Odom 0 Gmvel PacWGraval Slza�An n _in diameter <br /> Well Casing Dia,neter�r Casing iThiCknees/Gauge//ASTM Sched r c2si9gydliteel O Plastic 0 Stainless steel '04,MI <br /> Grout Seal Depth ft 0 Neat Cement(94 10 VW water)a 0 Sand Cement ��t s tgal water <br /> O Sentonite(20%solids) ❑Other MCI MENTAL HEALTH eD. <br /> Grout Placement Method O Pumped 0 Free Fell 0 Other ray""5 V16%wfdant I Accelerator n..) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0Other <br /> 0 Concrete Pedestal Dlmenslons:Width_ry Length R Thick In 0 Christy Box 0 Stove Plpe <br /> u P Q,%ubmerdbaC Turbine 0 Other HP Pump Sat It Standing Water Level R <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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED --� _ TITLE CEO OATE2/26/' 1 <br /> Pne'sRw-Genenl T .-D <br /> Sbre <br /> PVMP/VIFLLISL EDPPPRD% <br /> eS.IIR.iROM T1EMIGMMRY. <br /> H <br /> • <br /> y OE PARTMENT USE ONLY <br /> Application Accepted By Data—3I r t b Area 0 St 9 z] Employee ME <br /> Grout Inspection I Dale SPECIAL WBII Permit <br /> Pump Inspection I- Data / l WAIVERReceiVed <br /> Sell Boring Inspector By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc. Received CheaklYl Amount Date Permitl Invoke# Wall 10# <br /> Codes <br /> Into <br /> S Cash Remitted Service Request f{ <br /> sea a;� � �G97p >7�,� I16 SRoo 32 <br /> exo alae <br /> API NIiM>ua4Nrt <br />