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- , ILES <br /> T� ELLIPUPV P PERMIT <br /> SAN JOAQUIN GoUNT:'ENVIRONMENTAL HEALTI-i DEPT 9868 East Hazelton!-avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> N DN-V REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> 7 /� / rn <br /> JOB ADDRESS I J 70 �//Vt gal <br /> � CITYIZIP L-'-'11E4 fie^��b m <br /> CROSS STREET 1'/Z: )6/I/ APN OC73 -O /'-`� PARCEL SIZE 07,-- LAND USE APPLICATION# m <br /> cn <br /> OWNER HAME A&/Hr� c��/i•.� PNONE(Zm90 ?z N <br /> OWNER:-:DDRESS IP I 06k leejCITYISTATE/ZIP L1Y1Q/-t, X527 C <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 ❑ C-61 0 D-09 0 Other NUMBER ExPIRATION DAT E <br /> GEOGRAPHICAL INFORMATION: Coordinates)( Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water Systern <br /> If different from Owner: WaterSystern Name Contact Name or Phone Number <br /> I YPE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump 0 Purnip Replacement ❑ PUMP Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel PacIVGravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth Ift <br /> Weil Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other I-IP Pump Set_LV ft 'Standing Water Level O 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 L-VITI•I THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT] AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. Y0 <br /> MINIMUM X FLOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / JJ <br /> SIGNED r TITLE 17L/JJ'l ,V DATE c3/ZZ //;E <br /> of <br /> — J <br /> E H 1y <br /> CoA TMENTE NLY <br /> %Application Accepted By Dato �� t� T Area Employee IDlk� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date ZZ/ 1� WAIVER Received <br /> Soil Boring Inspection By Date `Constructed Well Depth <br /> COMMENTS <br /> PE Sc Received /'Check"V Amount Date Permit! Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> ,OT Vc SZ, OU <br /> 051 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />