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WELL/PUMP PERMIT <br /> SAH JOAQUIN COUNTY ENMONMEHTAL HEALTH DEPARTMENT /! 600 E.Main Street-STO&TON CA 95202 - (209)468.3420 <br /> NON-REFLWDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> 3011ADDaEss 7761 W. Undine Road Crlv/Zlr Stockton 95206 <br /> CROSS STREET Wing Levee Road APN 189-200-06 PARCELSIZB T:.AND VSZ APFUCAT[ONa <br /> OWHERNAME A.B.F. Farms Services PHONE 462-07nR <br /> OwNERADDRLTS Same Ctrv/STATPlLQ I . <br /> CONTRACTOR Delta Pump PnoNE 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CrrY/STATE/ZTP Stockton, CA 95203 <br /> SVCCONTRACTOR PHONE i <br /> SLMCONTRACTOR ADDRESS CITY/STATL ZIT <br /> LICENSE E3 C-57 XIC-61 0D-09 ❑Other NUMBER 724778 ExpmAnoNDATE 08/12 <br /> GEOcX4ymcAL "T1ON: Coordinates X Y Towasbip Range Section <br /> [1��' �"� IMImestic/Privste ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil SampiinyChanctcrization <br /> In WaN-rSyttemiff mt 6—Omer. ate sym. as smear e <br /> TYPE Or WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) M ofwells ❑Soil Borings) aabMiase ❑Gcotechnial I or Weals <br /> ❑Out-Of-Scrvi c ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pu Mm Re Imcemcnt ❑Pump Rep&Lr <br /> WrLL CoN.'TRUrnoN <br /> Drilling Metbod ❑Mud Rotary ❑Air Rotary ❑Auger Q Cable Tool ❑Push Point ❑Other I <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size In diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth a <br /> Well Caslag Diameter in Thickruras/Gauge/ASTM Sched ❑Stcel ❑Plsstic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Nut Cement(94 1b bag/5-10gal water) ❑Send Cement sock mts/7 gal water <br /> n <br /> ❑Bentonite(20ye solkis) ❑Manufacturer Spec%solids K Name ❑Specs on Filc ❑Specs Submined <br /> Groat Placement Method ❑Pumped ❑Free Pell 13 Other ❑Retardant/Accelerator(name) <br /> "DF-STA L Installed By ❑Driller Cl Pump Contractor ❑ Other <br /> F>aeercte Pedestal Dimentions:Width ft Length ft Thick in ❑Christy Bos ❑Stove Pi i f <br /> =Smersible ❑Turbine 0Other—HP--L—PumpSct 42 ft Standing Water Level 9 n <br /> 1 HEREBY kE476n THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL DE DONE IN ACCORDANCE WITD SAN Q <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNEII Tm.E CEO DATE <br /> 03/22/12 <br /> VX <br /> r <br /> t <br /> r AL <br /> ARTMENT USE ONLY <br /> Application Accepted By _ Date u L Area Employee lDM <br /> Grout Inspection By to ❑ SPECIAL Well Permit <br /> Pump Inspection By Date L ❑ WAIVER Received <br /> Constructed Well p <br /> COMMENTS <br /> PE SC Received heckW Amount Dsit Permit/ Invoice N Well IDX <br /> Codes Taro D Cash Remitted Service Request N <br /> AL3 P/ esti / U 53 cZ j <br />