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WELUP NlP�ERiNIIT <br /> SO.14 JOAQUIN 0-jW!T,f ENVIRONMENT,L.HEALTH DEPARTMErIT 1863 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAP FROM DATE ISSUED <br /> JOB ADDRESS �J .Jc./t/ ' V/�C LC, O � CITY21P �+�vj/ <br /> a <br /> CROSS STRFET /G� L.J� APN PARCEL SIZEZ- J LAND USE APPLICATION# <br /> m <br /> OWNER NAME /�� �6/- PHONE �O� ' �3 01�' __ N <br /> OWNER ADDRESS n CITY/STATE/ZIP 7 <br /> CONTRACTOR �i�X GRozs PHO!LE <br /> CONTRACTOR ADDRESS �� a C L7c� Cl-.Y/STATE/ZIP� <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP__ <br /> LICENSE ,�C-57 C-61 D-09 I Other NUMBE�77-36-)r EXPIRATION DATE_ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE jC Domestic/Private Irrigation/Agricultural ❑ Industrial i 1 Water Quality Monitoring i Soil Sampling/Characterization <br /> Public Water System _ <br /> If different from Owner: Water System Name Contact Narne or Phone Number <br /> TYPE OF WORK >14ew Well replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical n of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ><New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method•x'::�:rbiud Rotary ❑ Air Rotary 1 Auger C1 Cable Tool Push Point Other_ <br /> Proposed Well Depth 0 ft Excavation I—L— in diameter I I Open Bottom ><bravel Pack/Gravel Sizein diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter C_ in Thickness/Gauge/ASTM Sched7._,'�0 r.i Steel S41Iastic Stainless Steel Other <br /> Grout Seal Depth 16-0 ❑ Neat Cement(94 lb bag/5-10 gal water) _5g Sand Cement Zoo. _sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ,dumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By < Driller Pump Contractoro, Li Other <br /> Concrete Pedestal Dimensions:Width Y ft Lengthft Thick in I Christy Box Stove Pipe <br /> PUMP .''Submersible Turbine Other HP Pump Set ft Standing Water Level 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 101 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 /> MI(IU 24 ZUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED_5� �jH►__ TITLE&4JA'tYl- DATE <br /> Z <br /> O <br /> cm <br /> Z <br /> a <br /> LL <br /> T1_r1 14 <br /> I <br /> DFARTMENT U /E� ONLY <br /> Application Accepted B Date l �� Area Employee ID# �� <br /> Grout Inspection Cc Date Lv / I 1 SPECIAL Well Permit <br /> Pump Inspection By _ Date I I WAIVER Received <br /> Soil Borii g!ncpection By Date Constructed Well Depth _ft <br /> COMMENTS A&S4j <br /> of r <br /> PE Sc Received Check#/ Amour:' Permitt J <br /> Codes Info 8 Cash Remitted Date Service Request# Invoice# Well ID# r/� <br /> 7-4i< V3Nc, !Zq-'A-'L SEN-7�O-Y i <br /> VIS-t 6 S'=�_ <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />