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. , i : (, 3n,10 Sian 511011 ho PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)46£1.3420 <br /> NON-REFUNDABLE PERMIT 1 CALL(20911)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM <br /> FRROMMDDATE ISSUED <br /> JOB ADDRESS �� J� tZ CITY/ZIP Z' ' ! , <br /> CROSS STREET S APN Sr PARCEL SIZE/C-?r LAND USE APPLICATION# <br /> OWNER NAME A 40,21 — PHONE- S J Z_7•7- y <br /> OWNER ADDRESS m CITY/STATE/ZIP <br /> CONTRACTOR I'"�`�ffS ( `I PHONE-1,13y_ -'0_L<1_/Z.<1_ <br /> CONTRACTOR ADDRESS o /Q,? CITY/STATE21P�/ U <br /> SUBCONTRACTOR l / YK jp PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP /1 <br /> LICENSE 5-C-57 C-61 D-09 Other NUMBER-7_2 �' EXPIRATION DATE C <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System _ <br /> If different from Owner: _ Water Sy—stem _ Contact Name or'F{F cone um er <br /> TYPE OF WORK / New Well 1 Replacement Well I Well Alteration/Modification i 1 Other <br /> MonitoringWells #of wells i Soil Boring(s)S #of borings i #of borings <br /> O 9O Geotechnical <br /> Out-Of-Service Well i Out-Of-Service Well Renewal i i Cross-Connection Repair <br /> " Jew Pump I Pump Replacement Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method�Mud Rotary I Air Rotary i Auger i I Cable Tool Push Point Other <br /> Proposed Well DepthUz) ft Excavation l in diameter 1 Open Bottom ravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 41 in Thickness/Gauge/ASTM Sched Z-"- 0 Steel .c:Tastic Stainless Steel � Other <br /> Grout Seal Depth2_2:> ft Neat Cement(94 Ib bag/5 10 gal water) Sand Cement l(J :3 sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Methodir-Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 4k< Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other_ HP Pum Set______.,__ft Standing Water Level ft <br /> --- -- _!e, -e --- - --- - -- - —_.. -- -- -- _- --p-------f... ding - e <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 /> CURR`NIT ANC AC-.;'v'=--;'Y'= <br /> . ..� . - i7{Ti i THE CALiFvRiriA CONTRACTORS STATE LICENSE BOARD AND THAT I AM iN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI I UM 4 Z06— <br /> UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE ;ALL(209)953-7697 <br /> SIGNED TITLE_ _ �R.LS �" DATEI IL <br /> , <br /> I <br /> L <br /> Z <br /> W <br /> O <br /> E. <br /> - Z <br /> JJ <br /> L <br /> I <br /> EP RTMEN 'T,fUSE NLY v�/� <br /> Application Accepted ` Date _�-(/ C. �r Area Employee ID# lrO <br /> Grout Inspection By Date 111 � ❑ SPECIAL Well Permit <br /> Pump Inspection By l'1 .i Date � /I r7 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedCheck#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> b 2� aW�VIVO b(9 1 <br /> EHD 43-06 WELL/PUMP PERA"!T <br /> 4/30/12 <br />