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46 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN 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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 43135 60-1 L70 9k /'`V t A e CITY/ZIP 5fVa-*W1 q�L(J � m <br /> CROSS STREET "^1/�1� �//`�,t� APNNy��'�S 7]�V Vc��0 If PARCEL SIZE 0. LAND USE <br /> /A APPLICATION# <br /> OWNER NAME 1,J*/6f40I✓Iyn��� {J�'�'/l•f PHONE( f^s-/, !�3"g?D0 N <br /> OWNER ADDRESS 9 /D CITY/STATE/ZIP51O*:)r ll i �1 <br /> CONTRACTOR �(f( , t IL L• QPHONE �7 ZJyQrD� <br /> CONTRACTOR ADDRESS <br /> . ' VcLt/I -xAk— WQ (,(� 4- CITY/STATE/ZIP .J�V //J pMQ� �f��Q <br /> SUBCONTRACTOR W'ttxcGuag& Ek,�,acpt,/,�J��aA PHONE ?D�`7/��-(7857— 57gi! <br /> SUBCONTRACTOR ADDRESS 1 J 9�/G/.JC�/YiJ-) Ave.A CITY/STATE/ZIP E.sLal�J C / '5-32-/ <br /> LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 43 7v I47I EXPIRATION DATE d 3d P <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑p1d, <br /> tr <br /> I IV to ti rl a nc�t ❑ Water Quality Monitoring Soil Sampling/Characterization <br /> ❑ ren ro a r y a e on ac ame or one um er <br /> TYPE OF WORK ❑ Nero.t ft ,{�, jp�C ygrl��Q�(, tion/Modification ❑ Other <br /> ❑ MollnitGorl�1n1�1{►W!�'II'('sO)pj�r f�IIAAYYGG#of a IsG�p�To'f4��IBRo]1r4�tn #of borings #of borings <br /> }}�� 9O geotechnical <br /> ❑ dL(0f�a4I 6 Yt eted or Hl ce Well Renewal ❑ Cross-Connection Repair <br /> ❑ Neit 11Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary .Auger ❑.Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth _ft Excavation -'5 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 Cem (94 Ib bag/5-10 gal water) ` ❑ SarrdCemerit sack 1 gal water <br /> ❑ Bentonite(20%solids) Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedesta)Dimensions:Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> 1 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 /> M O ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE c <br /> NEE Mi <br /> 7.. <br /> IME <br /> �. <br /> p� I' <br /> ; N <br /> - 12 <br /> MMEMINK <br /> off mea <br /> ENE Mi IMMUNE <br /> MMMMF <br /> DEP RTMENT USE ONLY <br /> Application Accepted ByLkDate Z Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit 666 <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 1-4 z !� !c3 0`� aob� �IP <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />