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r <br />19605 <br />dA <br />WELL/PUMP PERMIT <br />SAN JOACUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JoB ADDRESS 19292 F. DAWN RD A PN 1 gc;f14 O 1 A CITY/ZtP STOCKTON 9 5 215 <br />CROSS STREET BTWN BERKLEY & SBOURITY WAY PARceL sIzE4 . 77 LAND USE APPLICATIoN## <br />OWNER NAME DAN BROWNING PHONE 2 0 9 482 0036 <br />OWNERADDRESS SAMF. CITY/STATEIZIP <br />CONTRACTOR Delta Pump 4T0r'KTON ARMATURE & MOTOR WORKS ff"Q. 209-466-9625 <br />CONTRACTOR ADDRESs 646 S. California Street CITYJ57ATEIZIP Stockton, CA 95203 _ <br />SUBCONTRACTOR d PHONE <br />SUBCO"TRACTOR ADDRESS <br />LICENSE 0 C-57 X C-61 0 D-09 ❑ Other <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />CITYISTA7EIZIP <br />NUMBER 724778 ExPIRATIONDATE 08/11 <br />Township Range Section <br />vv11wauwrnvate :7,trrlgaaon/agricultural 0 industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: a er ys em ame C-muut Name or Pnone NUMber <br />I YPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />G Monitoring Well(s) #,r of wells i✓ Soil Boring(S) # of borings 0 Geotechnical <br />❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement XXumD Rnoair n D„; „ W-11 r`__:__ <br /># of borings <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom D Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic 0 Stainless Steel 0 Other <br />Grout Sea] Depth ft C Neat Cement (94 lb bag15-10 gal water) C Sand Cement sack mix17 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method 0 Pumped ❑ Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />FEPIEDESTAL Installed By ❑Driller Pump Contractor ❑ Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box 0 Stove Pipe <br />PUMP 0 Submersible LITXrbine 0 Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY TNAT 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 />)ll 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO 7/7/2017 <br />DATE <br />NOTE: <br />PUMP SET & STANDING WATER LEVEL <br />IS UNKNOWN UNTIL THE JOB IS DONE <br />E,LP RTMENT U E N L Y <br />Application Accepted Sl <br />Date <br />Grout Inspection By Data <br />Pump Inspection Byi�wv�I,r,� Date .. W^ <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID#-%2ow6uv; <br />SPECIAL Well Permit T <br />WAIVER Received <br />Constructed Well Depth ft <br />WELL /PUMP PERMIT <br />