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X66277 � WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 1i�:PARTMENT lP+r <br /> I 304 E WEBFk—xVE 340 FL-ST �9}468-3420 <br /> �! NON-REFUNDABLE PERMIT CALL(209)953.7697 FOR INSPECTIONS EXPIRES 1 YEAR F <br /> I � EXPFROM DATE ISSUED <br /> Jog ADDRESS 6981 S. Roberts Road <br /> CITY/ZIP Stockton ' 95206 <br /> � `I CROSS STREET Highway 4a <br /> + EI d APN 162-110-04 PARCEL SIZE LAND USE APPLICATION# <br /> �{ OWNER NAME .Tose Gonzalez <br /> I�. PHONE 925-250-3188 <br /> t ; OWNER ADDRESS same <br /> I CITVISTATEIZIP <br /> CONTRACTOR Delta Stockton Pum pltoNE 466-9625 <br /> I� CONTRACTOR ADDRESS 646 S. California Street <br /> EJJJJ CITY/STATE/ZIP Stockton, CA 95203 <br /> !� SUBLONTRACTOR <br /> {I{ 't PHONE <br /> !I SUBCONTRACTOR ADDRESS <br /> !I $ CITYISTATEIZIP <br /> LICENSE ❑C-57 UC-61 ❑D-09 ❑OtherNUMBER 724.7"78 <br /> ' EXPIRATION DATE <br /> !� GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Township" Range Section <br /> E� INTENDED USE 1NDomestic/Private ❑i Irrigation/Agricultural 11 ❑ <br /> Industrial 'Water Quality Monitoring C3 Soil Sampling/Characterization <br /> I <br /> 11Public Water System <br /> {; If different from owner: r' <br /> I� .F ater ystem eme - ontact ameor one um er " <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole C3 Other <br /> E t <br /> ❑Monitoring Wells} #of wells 11 Soil Boring(s) #ofborints,l #of6orings <br /> C3 Geotechnical❑Well Destruction ❑Out-Of Service Well O Out-Of-Service Well Renewal" <br /> ❑New Pum $I Pum Replacement ❑Aum Repair I ❑Cross-Connection Repair <br /> � WELL CONSTRUCTION � <br /> I Drilling Method ❑Mud Rotary 0 Air Rotary ❑Auger ❑Cable Toal ❑Push Point LI Other <br /> I Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑Gravel Pack!Gravel Size <br /> ❑Conductor Casin in diameter (n ! <br /> g in diameter / Conductor Casing Depth' <br /> epth ft <br /> 'j Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic <br /> 13 Stainless Steel ❑Other <br /> !i Grout Seal Depth ft ❑Neat Cement(94 lb bag l5-10gal water) ❑Sand Cement <br /> ruck mix!7 gal water j <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name i ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall C3 Other ❑Retardant/Accelerator(name) <br /> I PEDESTAL Installed By ❑Driller ❑Pump Contractor [3 Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove,Pipe <br /> PUMP,- C[Submersible ❑Turbine ❑Other 'HPk' Pum 60 <br /> P Set ft Standing Water Level 15 ft <br /> I HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN - <br /> !j JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT`MY�REQUIRED LICENSE IS <br /> it CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> t <br /> AD <br /> MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> IGNTITLE CEO DATE 11/04/05 <br /> FT <br /> I <br /> E1 <br /> It 1 <br /> I i <br /> ni <br /> + . p et <br /> n D y <br /> FTI" 7 <br /> �l <br /> E <br /> II 4 DE PAR FME"NT USE ONLY <br /> Application Accepted By � �! �S <br /> Date � Area EmployeelD#,'r����� <br /> Date Grout Inspection By D <br /> 1 ae ❑ SPECIAL Well Permit q <br /> 1 <br /> Pump Inspection B Lb Date 11❑ WAIVER Received <br /> it <br /> Destruction Inspection By Date <br /> Constructed Well Depth It <br /> i1COMMENTS� (i/ �� �fa /1�� � -c�� 'dI�CG% Y� /f— w✓ <br /> PE 1) SC Received Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re nest# Invoice# Well ID#. <br /> ,�O !L o c21 OD - , <br /> E� p <br /> j-END 43.02-006 <br /> _816704 �! - - WEr,L PUMP PERMIT <br />