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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT '1363 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)463-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES `a YEAR FROM DATE ISSUED <br /> ii [�-7 G n L►'Bile h cc, �#5'LU <br /> � <br /> JOB ADDRESS 1 V f� � /+F. 1.���'Ar�PC, 11� IG�� CITY/QIP <br /> 1ri0 <br /> GROSS STREET �dl l j ,�9y✓�` "``i `.`y L 1 C - ��L PARCEL SIZE LAPID USE APPLLICATION 1/ m <br /> en <br /> OWNER NAME Ze'a ne 4!e J A 1/1C]`Il 1 N� I PHONE <br /> OWNER:'DDRESS t" ^ J ad CITY/STATEIZIP kl otkekn Ir <br /> CONTRACTOR M A s P l 1� �r i ,X11 3�iV� 1AAPHONE l J 2 <br /> L_L- �"i <br /> CONTRACTORADDRESS h rS CII(ISTATEIZIP (I�Yd' SA6' ret ;If <br /> ss l <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-6.1 ❑ D-09 ❑ Other NUMBER thAP.67•t EXPIRATIONDATE <br /> GEOGRAPHICAL INFOR TION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> IF different from Owner: a er 'ys em ame —Contact Name or one Number <br /> TYPE 01:WORK x1ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical ll of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Purnp ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling WIothod ud Rotan,, ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 3 SO ft Excavation 12- f_/ in diameter ❑ Open Bottom 'X Gravel PacldGravel Size.0 fa in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter .6 in Thickness/Gauge/ASTM Sched 7,60 ❑ Steel 'Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth iO' IZA ft ❑ Neat Cement(94 lb bag/5-10 gal wate/) ❑ Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placernent Method'(Pur'nped ❑ Free Fail ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Boit ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Otlier I-IP Pump Set ft `standing Water Level ft <br /> I I-IEREGY CERTIFY THAT T 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 /> _ MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED �^ -��— I 1 i^1 Xovs DATE r AP <br /> �1 It I <br /> it <br /> U <br /> .WFIRONIAE14TP L <br /> IV <br /> H E t1 <br /> A <br /> �� PARTMENT USE ONLY <br /> Application Accepted BAc Date Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> - <br /> � <br /> COMMENTS TA —/'7 t900 7 <br /> PE SC Received Chec Amount Permit/ <br /> Codes Info By ash Remitted Date ServiceReoluest; Invoice Well IW! <br /> c 3st/ 1 31�ll� Woo-5a,3i <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />