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4 <br /> e WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> Stockton,CA"952191 G7 5 <br /> JOB ADDRESS (azvid " CITY/ZIP. 1 (J D <br /> CROSS STREET ST)kKtIc � APN Imo/` PARCEL SIZE, _-�AND 60PPLICATION# m <br /> OWNER NAME Dino and Nicole Del Carlo PHONE contacU dinodel1O@yahoo.com y <br /> OWNER ADDRESS CITYISTATE/ZIP Stockton,CA 95206 <br /> CONTRACTOR <br /> Dan's Water Well&Pump Service,Inc PHONE (888)326-9355 <br /> CONTRACTOR ADDRESS 3494 Camino Tassajara#203 CI /STT Danville,CA 94506 <br /> SUBCONTRACTOR Li W 11 E1-.y- <br /> SUBCONTRACTOR ADDRESS ITY/ TATEIZIP p�/ <br /> LICENSE x C-57 C-61 D-09 Other Qayp�$X ' ed wittmat5 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y _ <br /> INTENDED USE Domestic/Private *Irrigation/Agricultural IndustrialWat r Qual;ty nitoring anta�o ampl n /C ra tgriz tion <br /> Public Water System h,rrnvtm )v(c0lt <br /> If different from Owner: Wates System Name TJRIG '-'" <br /> TYPE OF WORK x New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SoilBoring(s) #ofbonngs Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method x Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth (+,-)300 ft Excavation 24 in diameter Open Bottom #+Gravel Pack/Gravel Size 1/4 in diameter <br /> Conductor Casing_ in diameter / Conductor Casing Depth n/a ft <br /> Well Casing Diametert6 in Thickness/Gauge/ASTM Sched .250 x Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 ft Neat Cement(94 Ib bag/5-10 gal water) x Sand Cement 11 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method x Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller x Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <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 ACTIV WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP TI LAWS. r <br /> MINIM M UR ApV I REQUIRED FOR INS P TI "l`fS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE �1 ' DATE <br /> Ff <br /> C f <br /> i <br /> FD <br /> w , <br /> /1 �►/ DEPARTMENT USE ONLY <br /> Application Accepted By t / /V��— Date 2 Area Employee ID#-�Q�f3�Gv� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boning Ins ecti n By Date_ Constructed Well Dept ft <br /> CO,MM�ENTS ( �- 1/ <br /> L-/ <br /> PE SC Received Check#/ Amo nt Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request <br /> (go <br /> EHD 43-06 ��/PUMP PERMIT <br /> 4/30/12 <br /> V <br /> 9 <br />