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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 /> �7 �!1 � to <br /> JOB ADDRESS G��I �G tj(j tJ-�ll� �a5y>tD CITYIZIP VTCJA w P O �Z2b m <br /> CROSS S7REET�Ixy1<j ( V--N) APN dL',3 1 y Z-5 PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME a � Z _ rm <br /> n <br /> /PHONE(Iza�1) <br /> OWNER ADDRESS Z!c4 I Z-1-4� LI I'1 ij(Z—F—LLV'N 12-=v}-p CITY/STATE/ZIP ,jc-y- ��-P�u <br /> CONTRACTOR oetl 0. A( Jn >rU c, PHONE Zml 3701 <br /> CONTRACTOR S7Z0Z1 <br /> CONTRACTOR ADDRESS uSty�) A-e- VAY CITY/STATE/ZIP <br /> Glly - 15-RIG <br /> SUBCONTRACTOR <br /> � <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C wE <br /> -57 C C-61 C D-09 Other NUMBER v 4 EXPIRATION DATE o /Z <br /> GEOGRAPHICAL INFOR TI CO rdinates X Y Township Range Section <br /> INTENDED USE J I I tion I ta "I trl ❑ Water Quality Monitoring C Soil Sampling/Characterization <br /> C bli r <br /> If different from Owner: a er s e eUontact Name or Phone Number <br /> TYPE OF WORK ❑ Newtt//�1 A �abA'Vf' n/Modification Li Other <br /> C MO�IitW U l�ll�liwjAAI��{� #of boringsGeotechnical #of borings <br /> CD Out-New PGm ••���""YY�� lL ff--4 e1 iccle Well Renewal D Cross-Cc Repair <br /> t % r ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C Mud Rotary C Air Rotary ` Auger ,�C Cable Tool Push Point ❑ Other <br /> Proposed Well Depth 0' ZS` ft Excavation 661 in diameter C Open Bottom G Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched C Steel ❑ Plastic ❑ Stainless Steel a Other <br /> Grout Seal Depth ft C Neat Cement(94/b bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> C Bentonite(20%solids) C Other Sb U. C c"itu3�-,S \F �0 k�L� lF }l�� <br /> Grout Placement Method C Pumped C Free Fall C Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller C Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in C Christy Box <br /> 11 Stove Pipe <br /> PUMP C Submersibles-_; Turbine [=1 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE /L /�/A <br /> DATE <br /> , <br /> 2 <br /> D A R M ENT U SE O N L Y <br /> Application Accepted B`'— atm ! Area Employee ID# �'tl <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 /> PE SC ReceivedCheck Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />