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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 /> J �+ / t» <br /> JOB ADDRESS �lCa+��� `/ kZ�) CITY/ZIP �`–��c�l� 1 ��lC r^ <br /> D <br /> CROSS STREET � �� APN Zy S C C�O 3L PARCEL SIZE I I LAND USE APPLICATION# X <br /> m <br /> OWNER NAME DA\1<L uo(xy �! <br /> PHONE <br /> 1 <br /> OWNER ADDRESS –1 V bu CITY/STATE/ZIP �P N (/�C A <br /> CONTRACTOR �4IL `- 1�vJDcK�JJW ( 5 �vt IF_S Io C PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP Lob' / C LA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSEC 57 C-61 D-09 Other NUMBER EXPIRATION DATE 0`t (Z <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Doe i / rRa I n/A IC I t a Water Quality Monitoring Soil Sampling/Characterization <br /> Pu c terIfdi rent X <br /> rater tiygtern M ContactName or Phone Number <br /> TYPE OF WORK New W h i. ye YVg'AXoi1 Modification Other <br /> Moni �tutEiip�tjl(1 ('t/{1�11�y� � /��iih flYfi�� #of borings #of borings <br /> +/vrrT�vV�.•}7wWd is n�'@0Tgq XGeotechnicai <br /> Out-Of ery e Well ,,+,� ((,,�� x Ot S vice Well Renewal Cross-Connection Repair <br /> New P �nv �t af-fiu 1� Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotgry Air Rotary }/Auger Cable Tool Push Point Other <br /> Proposed Well Depth Ly) ft Excavation �o 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 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other SL3\L. C LA j 1061 , \F �_)C, �A-Lc v , lip- tlZ i L_tS�E Zc1.47011I-TF <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 /> y�– MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 2 <br /> SIGNED,`� / / �,li�� TITLE IT21-Ile, DATE <br /> 12o1120 <br /> r <br /> t; i .I <br /> N <br /> ff <br /> 94 <br /> �x ---I <br /> DEPARTMENTT USE ONLY <br /> Application Accepted BY /'l� h/� !L Date Area _ Employee ID# �� qA <br /> Grout Inspection By Date SPECIAL Well PeYA. <br /> Pump Inspection By Date WAIVER ReceiVW��lN1 <br /> Soil Boring Inspection By Date Constructed Well Depth �e ft <br /> COMMENTS V I .? ;'r,. <br /> QN J <br /> PE SC Received heck Amount Date Permit/ Invoice#`Th 4' I D7I r <br /> Codes Info By Cash Remitted Service Re uest# £pC <br /> 3� LL o ID N I I1(3�12. NT <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />