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17262 WELL/PUMP PERMIT <br /> SAN[JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-.STOCKTON CA95205.6232 •(209)4ue•3a2ri <br /> NON-REFUNDABLE PERMIT CALL 209 053.7697 I-OR INSPECTION, EXPIRES 1 YEAR r•RoM DATE I55UE0 <br /> Joe ADDRESS /]. r.nr•nct Trp, CITYIZIP Lodi 95240 <br /> CROSS STREET Hwy 12 APN 051-120-40 PARCEL512E27.6 LAND USEAPPLICATIONO <br /> OWNER NAME Steve SalVeStrin PHONE ';99 1177 <br /> OWNER ADDRESS ,16836 N. Rous Lane CITY/STATE/ZIPLodz CA 95240 <br /> CONTRACTOR Delta Pump PHONE, 209-466-9625 _. <br /> CONTRACTORADOREss 646 S. California Street CITY/STATEIZIP Stockton, CA 95203 <br /> — I <br /> SUBCONTRACTOR , PHONIC III <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE 0 C•57 M C•61 0 0.09 0 Other NUMBER 724778 EXPIRATION DATE 08116 <br /> I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township•__, Range. Section__ <br /> jNTENDED USE 0 Domestic/Private)p Irrigallon/Agricultural 0 Industrial 0 Water Quality Monitoring 0!Soil Sampling/Characterization I'I <br /> D Public Water System <br /> it ftwent from Owner, r em Name coma�t Name or 11nono Num0of - I <br /> TYPE OF WORK 0 New Well 0 Replace ment Well O Well Alteration/Modification 0 Other <br /> 11 <br /> O Monitoring Well(s) l 0 of wells 0 Soil Boring(s) eolb0`I0D' ❑Geotechnical o1 a0` °' <br /> 0 Out-Of•Service Well 0 OUt•O6ServICe Well Renewal 0 Cross•Conne6lon Repair <br /> anew Pum O Pump Replacement 0 Pump Re air 0 Raise Well Ctasin _ <br /> WELL CONSTRUOTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary , 0 Auger 0 Cable Tool 0 Push Point O Other <br /> Proposed Well Depth ft Excavation In diameter 0 Open Bottom O Gravel Pack/Gravel Size r.d�an �- <br /> ! <br /> 0 Conductor Casing In diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/Gaugo/ASTPA Schad O Steel 0 Plastic 0$lalnless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bag/5.10ga(welor) 0 Sand Cement sack m/x17 gal wat� <br /> O Bent illte(20%solids) 0 Other <br /> Grout Placement Method 0 PWmped O Free Fall O Other O Retardant/Accelerator;(namo) _ <br /> PEDESTAL Installed By O Driller O Pump Contractor ❑ Other <br /> O Concrete Pedestal Dlmonslons:Width ft Length ft T hlek In 0 Christy Box 0 Stove Pine <br /> PUMP 4;Submerili Turbine 0 Other HP—� Pump Set 1 AQ K Standing Water Level 1 f; It ) <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WlTi+ <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE 1141TH ALL <br /> WORKERS COMPENSATIO <br /> 7MINIMU 724 I•IOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED !/ 1 TITLE CEO DATE 43I 1 5 <br /> 4 _' I I LJ <br /> --�frd�i H- II_ <br /> Li <br /> T J <br /> _ D <br /> YJi - . <br /> INC U _Ir <br /> I <br /> F`j �f�jl 'LI -- <br /> DEPARTMENT U E N L Y <br /> i <br /> Application Accepted By DatP <br /> e Y /•2 Arae /9/�� Employee :)4E:!V4jf- <br /> groutt Inspection 0210 SPECIAL`r Jell Permit <br /> Pump inspection B Date `f <G l� <br /> WAIVER R@COIVC:I <br /> Soil Boring inspection By Data Constructed Well Depth <br /> COMMENTS iL�( <br /> S � <br /> PE SC Received hoc Amoun Date PormlV ImroleG# I <br /> Codes Info By Cas, Romilted Well DsService Roc uosl t! <br /> EHO 13.09 -"-`�--- <br />