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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE= PERMIT CA,P ft.. 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 800 E. MADRUGA RD. CITYIZIP LATHROP 95330 <br /> 0 <br /> CROSS STREET G UTHM I LLER RD. APN 2 41 —0 3—01 3 PARCEL SIZE 1 5 9_ 91kND USE APPLICATION# m <br /> OWNER NAME PHONq — <br /> OWNER ADDRESS P-n ROX 34Q 462 <br /> � '� <br /> ul <br /> rRCITY/STATE ZIPPF'NC-1 CA - CA 95231 <br /> CONTRACTOR Delta Pump--q.TnrKTnN ARMATURE & MOTOR WORKS EtNQ. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 X c-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1i6 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 0 Domestic/Private R�rigatlon/Agrlcultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System 1 <br /> If different from Owner: Water System Name contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other <br /> 0 Monitoring Wells) #of wells 0 Soil Boring(s) #of borings 0 Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well .e R �^ <br /> X)Vew P,um ❑ Pum Replacement 0 Pum Repair I II C <br /> ✓ i1 <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool ❑ Pus�Fj It �ilh�lnve ovn. d int; nt,t <br /> t u99 p p9- �J g, � <br /> Proposed Well Depth ft Excavation in diameter {o ,In B tt co rav vrr�l I vl, ti U In diameter <br /> D Conductor Casing in diameter / Conductor Casing <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bag/5-10 gal water)"! 0 Sand Cement sack mix17 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other 0 Retardant/Accelerator(name) MOO <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe (/pp <br /> PUMP 0 Submersible rbine ❑ Other HP Pump Set ft Standing,.Water Level ft C v <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN (s <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] AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. / <br /> h,'11UIVIc.GI'U'C .SLI. HOE)€y:11VANCE NOTICE [REQUIRED FOFIw INSPECTIONS <br /> SIGNED ? TITLE CEO DATEY_/-2� T 16 <br /> 1 <br /> GUTHMILLER RD. <br /> U s;�up <br /> I <br /> IVES <br /> PUMP/WELL Is located approx.0.427 2016 <br /> miles from Guthmiller Rd.at the end of ,{ <br /> n. <br /> the dirt tract. Y <br /> TAL HEALTH <br /> q EWCES <br /> NT <br /> --4E e ED <br /> FORM <br /> _ r� : _ 2016 <br /> MJM COUNTY <br /> ENViElONIVIPIN(TAP TMENT <br /> r DFP . RTME10T I! RF 0N1_Y <br /> 4 <br /> Application Accepted B Date Z / Area Employee ID# wp <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date d WAIVER Receives! <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ' <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Date Cash Remitted Service Re uest# Invoice# Well ID# <br /> EHD 43-06 <br /> 6/04/08 WELL/PUMP PERMIT <br />