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#7174 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3M6 FL-STOCKTON CA 95202-(209)46&3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR iNSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 8744 Roberts Road CITYILIP Stockton 95206 e <br /> CROSS STREET Howard APN 162-100-03 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME Sherman Chiu PHONE 415-279-1290 <br /> OWNER ADDRESS Same CITY/STATEJZIP <br /> CONTRACTOR Delta P=P PHONE 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITYISTATEIZIP Stockton. CA 95203 <br /> SUBCONTRACTOR PHONE. <br /> SUBibNTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 X]C-61 ❑D-09 ❑Other NUMBER 724778 E%PlRwrroN DATE V'7 <br /> GEOGRAPHICAL lwostNATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ®Domestic/Private ❑Irrigation/Aghcultural ❑Industrial ❑Water Quality Monitoring ❑Soil SamplingtCharacterization <br /> ❑Public Water System <br /> It diff—t from Owner: mer ystem N­ <br /> TYPE <br /> amnm M um r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> N of b-.p ❑Geotechnicai a or bonnip <br /> ❑Monitoring Wells) #of wells C3 Soil Boring(s) <br /> ❑Well Destruction ❑Out-Of--Service Weil ❑Out-0f--Service Well Renewal <br /> ❑New Pump X7 Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 11 ❑Neat Cement(94 lb hag/J.10 gal water) ❑Sand Cement .sack mix/7 gal water <br /> ❑Bentonite(206/6 solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped Cl Free Fail ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> 13 Concrete Pedestal Dimensions: Width_fl Length_ft nick in ❑Christy Boz ❑Stove Pipe <br /> E3IL� <br /> POMP M Submersible ❑Turbine Other HP� Pump Set 42 ft Standing Water Level—8 ft <br /> 1 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI ' M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 07/03/06 <br /> , U <br /> O N <br /> ALI LL <br /> U: <br /> LT .. <br /> —D PA TMENT U E O LY � <br /> Application Accepted Bb�, Date Area Empkyce ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By '•t� Date �/%rlf��<• ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck#/ ' Amount Permit/ Invoice# WellID# <br /> . <br /> Codes Info BCash Remitted Date Service R nest# <br /> t `3 0 1- V4 5 <br /> WELL PUMP PERMIT <br /> EHD 41-03•atM <br /> srfvoa <br />