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�■ -6-2014 16:05 FROM-DELTA PUMF 209466132E Tn:E6401?. 1 - <br /> son Anl <br /> 16887 WELL/PUMP PERMIT <br /> -3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1000 Eaet Hazelton Avenue• IRE O^+CA 04105-02J2 •(200)S00 <br /> NON-REFUNDABLE PERMIT CALL(209)993.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOa ADDRESS y,�'�� c^^"�^^ t. C,.Y,ZIP Stnrktori 9��175 <br /> CROSS SYRe?T--- ���-o�APN1 7 j-0 9-.n 1 1 __._PARCEL SIZE 0.20 LAND USE APPLICATION p <br /> OWNER NAME ,Jrjhn 1?-i torte _ PNOtIE <br /> OWNER ADDRE56 Q F4J c3qJ-n-S ve CtTYISTATe1ZIPStnrktn1`I. rn -- <br /> CONTRACTOR DeltrL P=A _ PHONE 209-466-4625 <br /> CONTRACTOR ADOREse 646 S,--California Street CRY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR AODRess CRY/STA-e/ZIP <br /> LICENBE U C-67 K C-61 0 D-09 0 Other NUMBER^724778 EXPIRATION DATE 08/14 <br /> GEOORAVHICAL INFORMATION: Coordinate$X Y Township_ Range seDtlen_ <br /> INruH uu G Ua9 §t DomostldPrlvoto 0 Irrlgatlon/Agrlcultural D Industrial 7 Water QusII!y MorIIorin0 0 Sell SamplingiCharactarizetlor <br /> D Publlc'Noter3Oystem <br /> ocem11 dKeront from +nen one r <br /> TYPS OF WORN --I New Well, 0 Replacement Well 0 Woll Alteratlon/Modlndatlon 0 Othor <br /> 0 Monitoring Weli(e) ;0 Of Wells 0$011 goring(s) aof boonge ❑ Geotechnical 0 O tw npe <br /> 0 Out-Or•Servlce Well 0 Out-Of-soMce Well Renewdl C C�oea-Conneclion Repair <br /> ew Pump 0 Pu.p Replacement D Pump Re elr 0 fiAlse Well Cesln <br /> Ru <br /> Drilling Method D Mud Rotary D Air Rotary 0 Auger D Cable Tool 0 Push Point 0 Other <br /> Proposed Well Deptn n excsvetlofl In dlemeter O Open Bottom 0 Gravel Pack/Orovel Size In diameter <br /> D Conductor Ceaing In diameter / Conductor Casing Depth h . <br /> Weil Cooing Olameter_In Thickness/Gauge/ASTM Schad 0 Stoel 0 PIIII 0 S1BInl9sa Steel �Olhor <br /> Grout Seal Deptt n 0 NOW COment(94 Ib 08g[15.10 gal Wdferl 0 Send Cement sack mlx/7 got water <br /> D Bentonite(20%sonde) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fell 0 Other Cl Roterdant/Accelerator name <br /> PeoESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensional Width It Length it Thick _Ir 0 Christy BOX C Stove Plpo <br /> Suomero101eO TurbIre 0 Other Ftp Pump get It Staneing Water Level n <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THIS WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LIC°NSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGN110 TITLE CEO DATE T nn �C <br /> I N <br /> I <br /> y <br /> E <br /> LIG <br /> 9 JN <br /> ��// n�....�" DEPARTMENT USE ONLY /!� �/- <br /> Appllcetlon Accepted By (� /VRT 0✓1 Oeto �t7(7 T Area �/O1 Employee IDR_�tom+ <br /> Grout tnspect.QD Data SPECIAL Well Permit <br /> Pump Inspection beta LO WAIVER Rocalvod <br /> Soll Boring InspeaT By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Data e� Invoice# Well ID# <br /> Codes Info Service Reauest# <br /> 143 o 90 /a 0-i OU7o73 <br /> th 43-00 <br /> WCLL!PUMP PERMIT <br /> 4: 13PM No. 7258 <br /> rle^: vac me Oct. 6. 2014 <br />