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r <br />WELUPUMP PERMIT P / <br />SAN JoAouw Comm ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue -STOCKTON CA 95205.6232 - (209) 4683420 <br />NON-REFUNDABLE PERMIT �/��C�A,.L..L (209) 953-7697 FOR INSPECTIONS ��tAI'll1ts 1 TEAR FROM DATE ISSUE[ <br />JOB ADDRESS 1//D Jf[ Qw ,b Crtr/LP —"C.Y �� <br />CROSS STREET VK W. <br />APN ` ' � r, , <br />O -/0 <br />PARCEL S��(L/AND USE APPLICATION # <br />OWNER NAME / vc� v/ !""�� ^-'� 'V V I U I ��' IJJJ PHONE <br />OWNER ADDRESS J'TMEr CnY/STATE/ZIP /J p <br />CONTRACTOR .O �1 I�f0�-W/VVI A JGIt (ilCE PHONE <br />CONTRACTOR ADDRESS AOD6K �fi Ltd //GPL�let CIT//STATEIZW<gdKT cA, 9563. <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS CRY/STATE21P <br />LICENSE I i C-57 i I C-61 I I D-09 I! Other NuYBER g l V C N i <br />PHONE <br />EXPIRATION <br />GEOGRAPHICAL INFoRMAnow Coordinates X Y Township Range Section <br />INTENDED USE KDomesticJPnvate i I Irrigation/Agricultural ! Industrial I I Water Quality Monitoring i I Soil Sampling/Charactenzation <br />i I Public Water System <br />If dill—n! from Owner Water Systm Narne Contact Narrte or Phone Number <br />TYPE OF WORK I I New Well i i Replacement Well ! i Well Afteration/Modification ! i Other <br />I I Monitoring Well(s) 9 of wells ! I Soil Boring(s) a of Wrings I I Geotechnical <br />! I Out -Of -Service Well I I Out -Of -Service Well Renewal I i Cross -Connection Repair <br />r or borings <br />Drilling Method i ! Mud Rotary I I Air Rotary I I Auger I i Cable Tool i : Push Point I I Other <br />Proposed Well Depth It Excavation in diameter I Open Bottom I i Gravel Pack/Gravel Size in diameter <br />I i Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter in Thidmess/Gauge/ASTM Sched I ! Steel I I Plastic i i Stainless Steel I I Other <br />Grout Seal Depth It I I Neat Cement (94 /b bagfSlO gal water) I I Sand Cement sack mixf7 gal water <br />i Bentonite (20% solids) I i Other <br />Grout Placement Method i i Pumped I I Free Fall i! Other i I Retardant / Accelerator (name) <br />PEDESTAL Installed By i I Driller I I Pump Contractor I i Other <br />I Concrete Pedestal Dimensions: Width ft Length ft Thick in I I Christy Box I I Stove Pipe <br />viii , tt Submersible i Turbine I I Other HP Pump Set /4!7 It Standing Water Level 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 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />Application Accepted By L/ <br />Grout Inspection By <br />Pump Inspection By til <br />Sal Boring Inspection By <br />COMMENTS <br />Date I <br />Date i ` t + y <br />Date <br />a <br />To <br />g <br />A <br />ECEIVEp <br />DEC ti 4 2011 <br />"r-"1 <br />TiSERV.r� EALTH <br />Area <br />- Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />EHD 4105 <br />6D4Dd <br />WELL /PUMP PERMrr <br />