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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468.34P0 <br /> NON-REFUNDABLE PERMIT CALL 209 9J3-7097 FOR?NSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> fA <br /> J08 ADDRESS 800 E. MADRUGA RD. CITY/ZIP LATHROP 95330 mD <br /> a <br /> CROSS STREET GUTHMILLER RD_ APN241 -04_Oj3 PARCEL szE159 . 9g,ND USE APPLICATION# In <br /> OWNER NAMEPHONN <br /> — ANTLIONY ��- �—L — <br /> OWNERADDRESS P-o_ RnX 34Q .�/I�� �61TY/STATE 1p�'V. J' I/N-- A 9522 <br /> CONTRACTOR Delta Pump—CmnC xmnN ARMATURE R MOTOR WORKS l ltbt 209-466-9625 <br /> CONTRACTORADDRESs 646 S. California Street CITY/STATEIZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 X C-61 ❑ 0-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/16 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE ❑ Domestic/Private R�rigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring C Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System amaon ac ame or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft 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 Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) 0400 <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other Fo. <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe t t/ <br /> PUrdP ❑ Submersible 5,jerbine ❑ Other HPjaa Pump Set ft StandingyJater Level ft 0B <br /> I 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. I <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED - TITLE CEO DATER ���2a 6 r <br /> t �i <br /> GUTHMILLERRD. <br /> IVED <br /> PUMP/WELL is located appmr.042 - / 2016 <br /> miles from Guthmlller Rd.at the end of <br /> the diff tract IE TAL H <br /> EALTH <br /> ER14CES <br /> NT <br /> ED <br /> 2016 <br /> couNTr <br /> FitO P TMENT <br /> DEP .4 R T-M E N T U ¢ F O ki L Y . <br /> 4 <br /> Application Accepted B� _ Date 7-7 Area Employee ID# �I D Vi J <br /> Grout Inspection By Date SPECIAL WOII Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#I Amount Date Permit/ Invoice# Well ll <br /> Info B Cash Remitted Service Re uest# <br /> EHD 4308 WELL(PUMP PERMIT <br /> 8104108 <br />