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WELL/PUMP PERMIT 07( 9. 601 <br /> SAN J^AQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS1 rT � ��r• I•r•Ty f`L���N/�"y CITY/ZIP !�y CIL r n "I "/ m <br /> D <br /> CROSS STREET �r�Al� a I�iJPy APNy4116ozoji. PARCEL SIZE ��� 7r LAND USE APPLICATION# m <br /> rn <br /> m <br /> OWNER NAME PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR ` Q11'1!ti(fir—fYIIC• PHONE �W �Iy� <br /> CONTRACTOR ADDRESS 20o l 4+-,c,4 r();->- 4d- Sm Goo CITY/STATE/ZIP T+oCkrV, \ 1 S__70 <br /> J 6 <br /> SUBCONTRACTOR W i "'I l/ �J PHONE ` 36eI—%Lq'2 <br /> SUBCONTRACTOR ADDRESS m. t, ! CITY/STATE/ZIP >'�-/Lk.ry, CIS—Id- <br /> LICENSE <br /> S—ILICENSE C-57 '1 C-61 I' D-09 I- Other NUMBER 7Z-0`j0q EXPIRATION DATE —��-ZJtL( <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ITienentfro <br /> Kitriga n! I It I i du ri I I Water Quality Monitoring Soil Sampling/Characterization <br /> O ner: Contact ame or Phone Number <br /> TYPE OF WORK N lt I ation/Modification I I Other <br /> p��n,� #of borings #of borings <br /> il ' "`" " �n (lt�(s) Geotechnicai <br /> Cts-�O rvice ell �,}���}� j�•Out- f-Service Well Renewal r Cross-Connection Repair <br /> Nk4] rif0 19d�r�rlt t -4 a air I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary Air Rotary >(Auger i Cable Tool Push Point I I Other <br /> Proposed Well Depth 7-0 ft Excavation — in diameter I Open Bottom I i Gravel Pack/Gravel Size in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel I I Plastic I I Stainless Steel I I Other <br /> Grout Seal Depth ft X Neat Cement(94 lb bag/5-10 gal water) I I Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) XOther 50, L�w120�21 4 .. 1+n CAI""►T' iG I a 0;19 nT <br /> Grout Placement Method 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 Other <br /> I Concrete Pedestal Dimensions:Width ft Length ft Thick in L! Christy Box i I Stove Pipe <br /> PUMP I I Submersible I Turbine I 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 <br /> �r�/REQUIRED <br /> /FOR INSPECTIONS <br /> SIGNED TITLE ,t12bli f Gwl�l�/1-, DATE _t <br /> Lf RYA NT <br /> D <br /> J q 13 <br /> A71—iq O NrY <br /> ui P <br /> ELNT <br /> DEPARTMENT USE ONLY ,(�(� / <br /> Application Accepted 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 ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 6/04/08 <br />