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I <br /> WELL�/7 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARME <br /> TNT-I /w) 600 E.Main Street-STOCKTON CA 95202 - (209)468-342D <br /> NON-REFUNDABLE PERmrr y/ (�CALL <br /> 2009 953-7697 rots INSPICiIONSE'^XPI�R]ES 1 YEAR FROM^DATE(ISSUED I <br /> JOB ADDRESS (�r�n L-l��/ :6 i., l�_��Jra-r-\ R.'�/�r� CmyrAgl�f., _1 11! 1�V �S✓J�- 1 � i� <br /> CROSS STREET f�)T1"'�-tel (\ t --� /� n�APN LASS S-1V -V� PARCIrLS1Zee�'-LANDU.IIAPPLIC.-nO/N!iI <br /> OWNER NAME - O N W F� l�--r�-]N�l�T •` PHONE <br /> OWNERADDRESS l-+ CITY/STATEILI► <br /> i <br /> CONTRACTOR Delta Purup no-209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street _ Cm'/STATE/zrP Stockton, CA 95203 <br /> SUBCONTRACTOR �— PHONE <br /> SUBCONTRACTOR ADDRESS Crry/STATErZAP <br /> LICENSE O C-57 XIC-61 O D-09 ❑Other NUMBER 724778 ExPtRAmN DATE 08110 <br /> GEOGRAPHICAL INPORMAnow Coordinates X Y Towaebip_ Range Section <br /> INTENDED USE O DAmestic/Privaic �Wjlmganon/Agriculturnl O Industrial O Water Quality Monitoring O Soil Sampling/Chusetenwion i <br /> OPublicWriterSyystem -r_ - - -�-_`� <br /> ff QiEve°t anm Owm Wer ysum oak Y ��ucr ante or M um�� <br /> TYPE OP WORK O New Well O Replacement Well O Wcli Alteration/Modification OOther ' <br /> O Monitoring Wali(s) a of wells O Soil Boring(s) s of maw O Geotechnical s othonogs <br /> O Out-Of-Service Well O Out-Of-Scm ice Well Renewal O Cross-Connection Repair <br /> 'ew Pump O Pump Replacement O Pump Repair W <br /> RV F.hL CONSTRUCTION <br /> Drilling Method O Mud Rotary O Air Rotary 0 Auger Q Cable Tool ❑Push Point O Other_ <br /> Proposed Well Depthft Excavation in diameter O Open Bottom O Gravel Pack/Gravel Sim in dwirw <br /> O Conductor Casing in diameter / Conductor Cuing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched O Stoel O Plastic O Stainless Steel O Other <br /> Grout Seal Depth R O Neat Cement(94 1b bog/J-10gal wafer) O Sand Cement sock mix/7 gal water f_ <br /> O Bentonite(2W.solids) O Manufacturer Spec%solids % Name O Specs on File O Specs Submitted <br /> ,Grout Placement Method C Pumpod O Fra Fall O Other O Retardant/Accelerator(name) <br /> peDEsrnL <br /> Installed By O Driller rap Cormsgo-r^// O Other <br /> i <br /> O Concrete Pedestal Dimeos{ s-Width i�R length r/ R Thick ri in O Christy Bos O Stove Pipe <br /> plmrP O Sub..ibk Turbine O Other HP_ �Pump Set ft Standing Water Level R I 0 <br /> 1 HEREBY CERTIFY'THAT l H <br /> HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNT( ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUDtED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TI1AT 1 AM IN COMPLIANCE WITH ALL <br /> a W_OR_ICERS COMPENSATION_WS. .�- <br /> T -- M111NI WUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNS 1 TOILE CEO DATE /69 ./ <br /> I i <br /> fII <br /> i <br /> l I <br /> I <br /> i <br /> I <br /> 9 <br /> O IN NTY <br /> —-• = -- - EX VI EfJf <br /> It <br /> DEPARTMENT USE O LY S <br /> Application Accepted By Date «t�0 Area Employee IDN T l(S <br /> Grout Inspection By Date ❑ SPECIAL Well Permit ( T <br /> Pump inspection By I<-t� Dote GD /S ❑ WAIVER Received <br /> Cooatructed ell Depth <br /> N ^^ It <br /> COMME -rS= �s(''-C/P-- <br /> PE SC Received C 1�L Amount Date PermlV - Invoice 0 Well DDM <br /> Codes Toro By Cash emitted Service Request p <br /> afSeo osv -77-2-2-3 sO'C/V 10 oo5d'S65 3 S <br />