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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST 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 2 13 2� P. H W 1 99 A), C�I"1A4 e P—ACITY/ZIP / Iy(/1 7,52 2 2—(D m <br /> D <br /> 1 0 <br /> CROSS STREET J MOT <br /> I YT OT APN 00 5-110017 PARCEL SIZE 2. 3cl LAND USE APPLICATION# a <br /> n T 1 , 1-012- <br /> � ? �y� y <br /> OWNER NAME 1'j���� � ��tJ. �'/��7� PHONE � /'�rJ��/�v`''im <br /> OWNER ADDRESS 2950 N- S?�i�`E �t� 9r �y CITY/STATE/ZIP ��j CA qqJ]/�1l <br /> CONTRACTOR 0 0 L !'. ``/``'4 A.> / -7ZZ�^DA3 It `�1• /�fS C• / PHONE 2_o/-, ,� "^3x201 <br /> CONTRACTOR ADDRESS �OG flN 6057;0,44_ MALI CITY/STATE/ZIP t6w (� � 7,�2 6 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP a <br /> LICENSE C-57 C-61 D-09 Othe! NUMBER �/ EXPIRATION DATE D ( /� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE DO t r I n/ ICU II Water Quality Monitoring xSoil Sampling/Characterization <br /> Pu1� ° <br /> If d ere a er T m on ac ame or one um er <br /> TYPE OF WORK New°ftrmit" "i tii7S 'red`WMIOuton/Modification Other <br /> MonMWMj _'n <br /> tJ' #of borings #of borings <br /> {� elJsCr 1I <br /> Out (Geotechnical- r} a Well Renewal Cross-Connection Repair <br /> New �� f it Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary xAuger Cable Tool Push Point Other <br /> Proposed Well Depth 10-1'>- ft Excavation Q-(c, 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) VOther IC. CU7-r(A_�C7S <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft 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 /> MINIMUM.44 HOUR ADVANCE NOTICE /RE/Q,(UIREED FOR INSPECTIONS <br /> SIGNED " TITLE PILJ1xiC o DATE 6-10 -I L <br /> z <br /> Ra = m r <br /> z �L <br /> F � 4 <br /> w <br /> a <br /> ahml Rd E JaWt Rd E Jahant Rd ,tananl Rd <br /> Sid <br /> m <br /> + z <br /> Lod'Arport <br /> EK L <br /> L' <br /> tt <br /> D PA TMENT USE ONLY <br /> Application Accepted B DatArea Employee ID#.,�q <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> lk <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B �est� Remitted Service Request# <br /> E H D 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />