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4 <br /> t <br /> AA,-A --a09_ ff3S- 0&/0 <br /> ' WELL/PUMP PERMIT - <br /> SAN JOAQUIN COUNTY ENNRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96206 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALLL X209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _ t'l�!' aL"K \�' Cln•Zl, Lattv�p v5 tii� r7i <br /> CROSS STREET S Freeway Underpass --APN 23Q03001 PARCEL SIZE 1566 All LAND USE APPLICATION 8 r <br /> OWNER NAME Susan Dell'Oso PHONE p <br /> OWNER ADDRESS 73 W Stewart Road CrrYISTATEl21P Latluop C ah(ernw,95330 <br /> CONTRACTOR ENGEO Incorpceawd PHONE 209-6&&-70(lo <br /> CONTRACTOR ADDRESS 580 N %chum Suite.4 CITY/STATEf21P Ripon/Cahfiomw/95366 <br /> SUBCONTRACTOR 4iegg Drilling&Testing In, PHONE 562-427-6899 <br /> SUBCONTRACTOR ADDRESS 2726 Walnut A,enue CITYISTATEZP SionaA HiA I CA/90755 <br /> LICENSE XC-57 C-61 D-09 Other Numm 485165 ExPIRATioN DATE 1/11116 <br /> GEOGRAPHICAL INFORMATION: Coordinates X 37 779343 Y -121 302945 Township_ Range Section_ <br /> INTENDED USE DomestwiPh9ate Inlgation/AgricURural Industrial Water Quality Monitoring al Sampling/Characterization <br /> Public Water System <br /> II different Mom 0r er ys ern oril&d Narne or .one Nurnne, <br /> TYPE OF WORK New Well Replacement Well -Well Alteration/Modification Other <br /> Monitoring WeA(s) -A of well; Til Boringls)_ _ 0 o eodngs ,,JGeotechnlcat�eot noirys <br /> Out-Of-Service Well t Out-Of-Service Well Renewal Cross.C2necbon Repair <br /> New Pump Pump Replacement Pump Repair Raise Wel Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary Arc Rotary Auger Cable Toot Push Point Other <br /> Proposed Well Depth 50 If Excavation b in diametel Open Bottom Gravel Pack/Gravel Size In diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter_in Thicknes;/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 R )"Vest Cement(94 14 Dag/5 10 gar water) Sand Cement sack mrx/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped Free Fall Other Retardant I Accelerator(name) <br /> 9 A Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions Width R Length it Thick in Christy Box Stove Pipe <br /> uM Submersible Turbine Other HP Pump Set ft Standing Water Level h <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADV. OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953 697 <br /> SIGNED`—� TITLE EfN�t'/�- DATE <br /> 4 zoos <br /> F ME�MY <br /> EYT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date-4�k � Area O > ( � Employee IDa <br /> Grout Inspection By \\\ Date SPECIAL Well Permit <br /> Pump Inspection B Date WAIVER Received <br /> Sod Boring Inspection8 Data Constructed Wall Depth K <br /> COMMENTS ti< - I, <br /> PE SC Received Cheekav Amount Date PertnW Invoice Well IDN <br /> Codes Info By Cash Remits Service Requests <br /> -ee we� ,'ems ♦ <br /> WELL PUMP KgMIi <br /> 44(02 <br />