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. , I : C 4, 3n-10 Scan 511�Iil �Yv► <br /> \IVELUPIJMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NUN-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Cn <br /> ZJOB ADDRESS CITY/ZIPm <br /> � r 2 f � O <br /> CROSS STREET S APN PARCEL SIZE/6-� r LAND USE APP/PLICATION#L� <br /> OWNER NAME _�J/ I'Y� /�/� Ro I 1 f p PHONE <br /> OWNER ADDRESS L� CITY/STATE2IP <br /> CONTRACTOR '~'rS PHONE 7 y` '-/' <br /> i ,(.�,X#-(r t <br /> CONTRACTOR ADDRESS o]�r � /r ���" CITY/STATE/ZIP <br /> SUBCONTRACTOR 4 �(1 1 !/ IV PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -C-57 C 61 D-09 Other NUMBERT7 � EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring I Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System flame Contact Name or Phone Number <br /> TYPE OF WORK <New Well i Replacement Well Well Alteration/Modification I Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings I Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal I Cross-Connection Repair <br /> ' New Pump Pump Replacement Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method"�Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well DepthZ 30 ft Excavation Ll- in diameter I Open Bottom Xravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> 12pWell Casing Diameter 4— in Thickness/Gauge/ASTM Sched �0 I Steel .Plastic Stainless Steel i Other <br /> Grout Seal Depth7-!2:> ft Neat Cement(94 Ib bag/5-10 gal water) XSand Cement if -_sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method dumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 4< Driller I Pump Contractor Other <br /> Concrete Pedestal i Dimensions:Width=jL ft Length ft Thick in I Christy Box I I Stove Pipe <br /> PUMP Submersible' Turbine Other—___-__— HP� __ Pump Setft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SA14 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CUR!?ENIT AND A .f Y E WITIX THE CALif•ORNiA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI I UM 4ZHUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE ;ALL(209)953-7697 <br /> SIGNED - _ TITLE (A DATE ' <br /> I <br /> L F � <br /> Z <br /> _ Z <br /> 6. <br /> YN <br /> I <br /> EP RTMENT USE NL/Y <br /> Application Accepted - ` lute �l v Area Employee ID# �0 <br /> Grout Inspection By Date l�lll (0 11 SPECIAL Well Permit <br /> Pump Inspection By Date r7 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B _Cash Remitted Date Service Request# Invoice# Well ID# <br /> b a oll U' y-��1- bs^ W��O3��►21 <br /> o b5 W D �I a2 <br /> EIAD 43-06 WELL/PUMP PERAR!T <br /> 4/30/12 <br />