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SISCONED <br /> WELL/PUMP PERMIT <br /> SIN.JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> t_n <br /> y m <br /> JOB ADDRESS / S e 10� / /Q � � rl _ CITY/ZIP 76 <br /> CROSS STREET C33I 011i _k2! � KJ APIN 2"/2 O J I PARCEL <br /> SIZE /, 9 LAND USE APPLICATION# L <br /> OWNER NAME N-01 I I �_ `♦ 0*0NE <br /> OWNER ADDRESS /5 b twc,� CITY/S TE/ZIP Te#<�f 7,T,3 <br /> CONTRACTOR fQ /I C _ PHONE <br /> CONTRACTOR ADDRESS /� `f/^� CITY/STATE/ZIP <br /> SUBCONTRACTOR __ PHONE _ <br /> SUBCONTRACTOR ADDRESS C <br /> /�IT <br /> �/Y/STATE/ZIP <br /> LICENSE C-57 'I C-61 i D-09 [1 Other NUMBER 734121 d EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X _ Y Township__ Range Section__ <br /> INTENDED USE omeStiC/Private [ Irrigation/Agricultural U Industrial i-i Water Quality Monitoring U Soil Sampling/Characterization <br /> !I Public Water System _ <br /> If different from Owner: tilery� stem N ameactIName or Phone Number <br /> TYPE OF WORK ew Well eplacement Well ❑ Well Alteration/Modification ❑ Other <br /> U Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings _ Geotechnical #of borings <br /> D Out-Of-Service Well a Out-Of-Service Well Renewal [I Cross-Connection Repair <br /> LI New Pump Pump Replacement CI Pump Repair 11 Raise Well Casing <br /> WELL CONSTRUCTION _ <br /> Drilling Method fKud Rotary f i Air Rotary [i Auger L 1 Cable Tool U Push Point [7 Other <br /> Proposed Well Depth Y00 ft Excavation l t in diameter 7 Open Bottom 111�vel Pack/Gravel Siz 6 in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 0;— in Thickness/Gauge/ASTM Sched J;dd< ( _t Steel lastic C; Stainless Steel D Other <br /> Grout Seal Depth 1120 ft ' Neat Cement(94 lb bag/5-10 gal water) J Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) '1 Other <br /> Grout Placement ethod WPumped :I Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By :.I Driller ] Pump Contractor Other <br /> ` Concrete Pedestal Dimensions:Width ft Length ft Thick in F II Christy Box n Stove Pipe <br /> PUMP i Submersible,' Turbine I; Other HP Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE ;x;01-" ":LL 132 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 CO PENSATION LAWS. <br /> MI MU 4 ADVANCE NOTICE REQUIRED FOR INSPECTIO -- P�.EASE CALL (209) 953-7697 <br /> SIGNED TITLE if DATE 7 __ <br /> olk <br /> "7 <br /> le <br /> A <br /> Elm- <br /> c ' <br /> CA Q UN <br /> JJ E T L <br /> 4— <br /> I'll <br /> M-Ak <br /> DEPARTMENT S ONLY / <br /> Application Accepted By.5A� Date Area ! Employee ID# <br /> Grout Ins ection B Y �� Date Ll SPECIAL Well Permit <br /> GC <br /> r <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth _.. ft <br /> COMVE:NTS <br /> PE Sc Received Check# Amount Per i <br /> Codes Info B s Remitted Date Service Request# Invoice# Well ID# <br /> g <br /> �Z;51 s i� <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />