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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT #1 1317 600 E.Main Street-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 512 N. Dewitt Road CITYIzIP Linden 95236 <br /> CROSS STREET CO peropolis Rd. APN 3 �3� PARCEL SIZE Z-73 LAND USE APPLICATION4 <br /> OWNER NAME Sal & Judy Rivera PHONE 887--2725 <br /> OWNER ADDRESS P.O. Box 1121 CITY/STATE/ZIP Linden CA 95236 <br /> CONTRACTOR Delta Pump __ __. PHONE 209- 66-9625 <br /> CONTRACTORADDRESS 646 S. California Street cm/srATwzrr Stockton, CA 95203 - <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> [LICENSE ❑C-57 XXC-61 ❑D-09 ❑Other NUMBER 724778 EXPIRATION DATE 8 C I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE M Domestic/Private r a❑:r igatian/Rgrcul ura' ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization I i <br /> ❑Public Water System <br /> ff different from Owner: Water SyMm Name Contact N=c or Moric Nurnber <br /> TYPE OF WORK ❑New Well M Replacement Well ❑Well Alteration/Modification 0 Other <br /> ❑Monitoring Wells) #of wells [ISoil Boring(s) k of borings ❑Geotechnical k of borings <br /> Cl Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑Now PumpMum Replacement ❑PumpRepair <br /> i WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger Q Cable Tool CI Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft `V <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic p Stainless Steel ❑Other <br /> Grout Sea] Depth ft ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Groat Placement Method 13 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ' <br /> ❑Concrete Pedestal Dimensions:Width ft Length R Thick in ❑Christy Box ❑Stove Pipe ('(� <br /> ]RSubmersible ❑Turbine ❑Other HP 3 Pump Set 200 ft Standing Water Level L 35 ft <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 i <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. _ <br /> iIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS j <br /> SIGNER Tr-LE CEO DATE 08/21/09 <br /> f <br /> U <br /> E <br /> I � <br /> Iv O <br /> OTI <br /> TT' I. J.. <br /> :=': - 1. Z-,_ - -I. <br /> DEPARTMENT USE ONLY , ! <br /> Application-Accepted By Date ZS C Area --. Employee LIDO <br /> Grout Inspection By 7 Date ❑ SPECIAL WeII Permit <br /> Pump Inspection G° �' DateCi ' ❑ WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received ChecTdl Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re nest# Invoice# Well ID# <br /> 381 oQQ2,3Zr� <br />