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X15455 WELI -PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 952,\�09)468-3420 <br /> NON-REFUNDABLE PERMIT CALL.(209 7697 FOR INSPECTIONS EXPIRES I YEAR FROM DA'Z'E ISSUED <br /> JORADDRess 5184 W. Highway 12 clrvlzrP Lodi, 95242 <br /> a <br /> CROSSSTREET 1 5 APN 055-160-22 PARCELs.1 LAND USE APPLICATION# <br /> OWNER NAME Frank C. Alegre PHONE 368-7664 <br /> OWNER AAW W Highway 12 CITYISTATFJZIP Lodi CA 95242 <br /> CONTRACTOR Delta Stockton Pump PHONE 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITYISTATEIZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PRONE <br /> V <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP 111 <br /> LICENSE ❑C-57 C-61 ❑D-09 ❑Other NUMBER 724778 E%PiRATION DATE 1` <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑Irrigalion/Agricultural 13 Industrial ❑Water Quality Monitoring <br /> ❑Public Water System ❑Soil Sampling/Characterization <br /> e <br /> Ifdiffe of from Own .1" ysrem ame ontast emeor Phane N,rnbe, <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> rin <br /> ❑Monitoring Wells) #of wells ❑Soil Boringpnr6o <br /> Boring(s) � ❑Geotechnical a oTUodngs <br /> ❑Well Destruction ❑Our-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump 0 Pump R lacement 0 Pump Repair 13 Cross-Connection Re it <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched CI Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941h bag/5-1Ogal wafer) ❑Sand Cement ,tack mix l7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File 13 Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other q Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width R Length ft Thick in ❑Christy Box ❑Stove.Pipe <br /> PUMP IXSubmersihle ❑Turbine ❑Other HP Pump Set 63 R Standing Water Level 20 ft <br /> I HEREBY CERTIFY THAT 1 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 /> ,—*HMM"4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 03/23/05 <br /> to <br /> 4E­ <br /> Q <br /> C <br /> • N <br /> �DV NT USE ONTLIYe� �,.�Application Acceptedte Q 7�d W Area /J✓/ Employee ID#,�-✓�V ��!f <br /> Grout Inspec on Date ❑`S`PECIAALL Well Permit <br /> Pump[nspec-on By - Dat �, 'j ❑ WAIVER Received <br /> Destruction Inspection By Date <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check# Amount Date PermiU lrtvoic¢# Well[INF <br /> Codes Info B as Remitted Service R uest# <br /> EHD 43-02-M <br /> XlNai <br /> WELL PUMP PERMIT <br />