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r' 00-7A WELL/PUMP✓l <br />jr PERMIT <br />SM4 JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205.6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JosADDREss 2201 <br />W. WASHINGTON ST. <br />STOCKTON 952-3 m <br />1CROssSTREE7 <br />CITYIZIP <br />AGRT <br />BUSINESS CIR Ptv vn <br />_� � <br />PARCEL SIZE 9 5 - 91ND t fSE APPLICATION <br />?' <br />ti <br />(OWNER NAME PORT <br />OF STOCKTON <br /># <br />P1.,o�09-915-1805 <br />M <br />OWNER ADDRESS P.O. BOX 2089 <br />CITYISTATFJZIP STOCKTON CA 95203 <br />CONTRACTOR Delta. Pvmn—ryTs7t,KTnR ARMA?�TTRT� A <br />iVj{�ry�(�R <br />Wnj�K <br />CONTRACTORADDRE3s <br />646 S. California Street <br />CITY/STATE/ZlP Stockton CA 95203 <br />SUBCONTRACTOR <br />PHONE <br />W9COt1TRACTOR ADOFZLagg <br />LICENSE C C-57 X C-61 ❑ D-09 <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />INrEN___ oED UsE ❑ DomestiGPrivate alrrigatic,�ur,yncui�ural a industrial p Water Quality Monitoring 0 Soil Sampling/Characterization <br />p Public Water System <br />I lI difluront from Owner: a yr ays em amo <br />on ac eine or ono urn ar <br />TYPE,-,- • OF Wp1�K ❑New Well p Replacement WeII ❑Wel! Alteration/Modification ❑ Other <br />Monitoring Wells) # of wells Cl Soil Boring(s) # of borings n or borings <br />IDU Out -Of -Service Well G Geotechnlcat <br />❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pum ❑Pum Replacement um Repair <br />WELL CONSTRUCTION ❑ Raise Well Casing <br />Drilling Method C Mud Rotary ❑ Air Rotary D Auger ❑ Cable Tool p Push Point ❑ Other <br />Proposed Well Depth ft Excavation ^ in diameter ❑ Open Bottom p Gravel Pack/Gravel Size <br />7 Conductor Casing in diameter / Conductor Casing Depth ft in diameter <br />Well Casing Diameter ____. in Thickness/Gauge/ASTM Schad <br />Grout Seat De th _ ❑ Steel D Plastic D Stainless Steel ❑ Other <br />p ft C Neat Cement (94 Ib baq/5.10 gal water) p Sand Cement <br />C Bentonite (20% solids) ❑ Other sack mixl7 gal water <br />Grout Placement Method p Pumped p Free Fail p Other <br />❑ Retardant /Accelerator (name)„ <br />PEDESTAL Installed By ❑ Driilor ❑Pump Contractor p Other <br />__ ❑Concrete Pedestal Dimensions: Width ft Length ft Thid< in n r;,.;�.., o_.. � ... _ _. <br />CITY/STATE/ZIP <br />❑ Other NUMBER 724778 EXPIRATION DA <br />Y Townsh(p _ Ranae co�r;�r <br />u0mersible❑ Turbine G Other --- <br />HP _'_5Pump 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. 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 COMPENSAA' I'U1A4wSr-_, <br />Application Accepted 9> <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring inspection By <br />COMMENTS <br />�p <br />EHD 43.08 <br />8/04/08 <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE CEO <br />DATE <br />Date <br />Date <br />Date <br />Date <br />Date <br />HEALI-H <br />Area_ ~� Employee 1D#AL1qC-0� <br />SPECIAL Weli Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />9.1271 NJ I' :v M 3s -/ `s <br />Invoice # <br />Weft ID# <br />WELL /PUMP PERMIT <br />