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I I I WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL <br /> �� �Q CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS () /'(J /J e-aS itrit- f4�`C R52 �1 <br /> QC ^ CITY2IP_ "n I 11+ m <br /> CROSS STREET__ tIDf�P� LN APND8'S-a9--Ol 65 <br /> I PARCEL SIZE / LAND USE APPLICATION# Q <br /> OWNER NAME OL J tmn <br /> A&r-K M S PHONE �� ���-qy 2 W <br /> OWNER ADDRESS J/^)`/-� & CITY/STATE/ZIP <br /> CONTRACTOR Delta PMp RTOCKTON ARMATURE R MOTQR WORKS MMQ-. 209-466-962 _ <br /> CONTRACTOR ADDRESS 646 S. California Street CITYISTATE/ZIP Stockton. CA 95203 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATFJZIP <br /> LICENSE . 0 C-57 Xi C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATIONDATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> C Public Water System <br /> If different from Owner: Water System Name —mact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells O SoilBoring(s) #ofborngs L1 Geotechnical'--n".of b°,rngs <br /> ❑ Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair - ' `• IN <br /> ❑ New Pump 0 Pump Replacement 1114ump Repair ❑ Raise Well Casin R <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other J111 2 1 20;9 <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gra I <br /> z �,—in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft J" """try COUNTY <br /> Well Casing Diameter in Thickness/Gau Thickness/Gauge/ASTM Sched ENVIRONMENTAL <br /> g ❑ Steel 0 Plastic 0 Stainless SteWALROIIT i �-- <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement <br /> sack mrxRat water <br /> � Bentonite(20%solids) 73 Other <br /> g <br /> Grout Placement Method 0 Pumped ❑ Free Fall C Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Levelft <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 AL50 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 COMPENSATjQN..LAWS.... <br /> WN <br /> SIGNED <br /> NOTICE REQUIRED FOR INSPECTIONS _ <br /> JIGNED -----_---___ T.- CEO <br /> DATE <br /> Oka, <br /> ti <br /> Ar <br /> Application Accepted By Date Area LC <br /> Employee ID# <br /> Grout Inspection By Date SPECIAL W@II Permit Inspection By � Date- WAIVER R@C81V@Cl <br /> Soil Boring Inspection By 4Date <br /> COMMENTS Constructed Well Depth ft <br /> =� b� ll�W -i 0 01VQ <br /> PE SC Received Permit/ <br /> Codes Info B ash Remitted Date Service Re uest# Invoice# Well ID# <br /> 2,1,o -7 Wen 9� <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />