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Niftole ..O.' <br /> WELLIF (rN .,: 7"jr.... <br /> : I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - ':., 5-I: I ;BEET-STOCKTON CA 95202-(209)468-$420 <br /> NON-REFUNDABLE PERMIT CALL(209i$: EXPIRES'I YEAR FRofi DATE ISSUED <br /> Job©R�EsOs Lower Sacramento Rd and Unil., , - ,,—Stockton �D <br /> CROSS STREET Eight Mile Rd APN PA?--:1 f:.ZE LAND USE APPLICATIONN_ O <br /> OWNER NAME City Of Stockton PHONE 209-937-82.12' 'Iy <br /> OWNERADDRESS 425 N. El Dorado StreetCITYISTATEIZIP Stockton, CA 95202 + <br /> CONTRACTOR Blackburn Consulting PHONE 209-522-6273 <br /> CONTRACTOR ADDRESS 4622 Glass Court, Suite A CITY/STATE/ZIP Modesto, CA. 95356 <br /> SUBCONTRACTOR Precision Sampling PHONE 209-465-8712 <br /> SUBCONTRACTOR ADDRESS 2365 Wigwam Drive CITVISfTaTE/ St6ckton, CA. 95205 <br /> �j2{1P <br /> LICENSE R'C-57 ''C-61 0-09 Other NUMBER ( �2) ! EXPIRATION DATE t rt'�>r�! C.•. <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private D Irrigation/Agricultural _Industrial '.-;Water Duality Monitoring x Soil SamplingiCharacterzation <br /> Public Water System <br /> If different Iron vMtor Uystem Naire cn a ane or sono umoer <br /> TYPE OF WORK _•New Well r Replacement Well Well Alteration/Modification Other i <br /> 9 MonitoringWell(s) 1 #WW,ings 11 gorborinas <br /> ) #Of _;Soil Bering(s) n,Geotechnical <br /> Out-Of-Service Well Out-Of-Service Well Renewal D Cross-Connection Repair , <br /> "?New Pum _Pump Replacement C.Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method i Mud Rotary .'3 Air Rotary >Auger i'Cable Tool n Push Point Other <br /> Proposed Well 12 Borings to 100' 2 Borings to 70 1 Monitoring Well to 50' <br /> - - --- — — -- {{2 Borings-to 25 -- ------!-Borings-to-20'--- 3—Borings to 10- <br /> Well Casing L — _____,. _,,,,,,,,,,,,,_. _ _•----..-. ( - <br /> Grout Seal Depth 50 it N Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water j <br /> Bentonite(20%solids) :?Other f! <br /> Grout Placement Method 1 Pumped r Free Fall X'Other Tremmie .. Retardant/Accelerator(name). <br /> PEDESTAL Installed By f:;Driller 0 Pump Contractor D Other <br /> Concrete Pedestal Dimensions:Width If Length ft Thick in D Christy Box 0 Stove Pipe I <br /> I <br /> PUR1P Submersible-Turbine D Other HP Pump Set If Standing Water Level It <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. 1 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 COMPENSATION LAWS. <br /> "I U1., 4 H(OIJ Dt/ANCE NOTICE IQUIR D FOR INSPECTIONSr o <br /> SIGNED - ' 'c".•'•�-%T TITLE �,-r.'`C'. �` r I DATE 3 1 O O o <br /> i <br /> Sipe, Att a h �t <br /> DEPARTMENT USE ONLY (� / t <br /> Application Accepted By Date Area Employee ID#3 "o <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date I- �____ Constructed Well Depth ft - <br /> COMMENTS t64,�5 '�d+ �d ,>.6��.j �/1Q _--!?-t2 <br /> PE SC Received Check#/ -Amount Date PermiU Invoico# Well IDA <br /> Codes Info B Ca Remitted Service Re uest# <br /> Lo_l �� t3 53555 <br /> [MC 47.06 WELL-PUMP PERMIT <br /> eRe/Gr <br />