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JAI", �FVFDI( (� ONELL�PIJMP PERMITfU�(U <br /> o ` /AN J�OUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> clrvrziP <br /> JOB ADDRESS �_._ _ <br /> f 7 <br /> D <br /> CROSS STREET_. _ C ,. PNS_ J -(,(o-_—PARCEL SIZE r(91 LAND USE APPLICATION# m <br /> OWNER NAME � "v '-�. _ PHONE <br /> OWNER ADDRESS ��17��- CITY/STATE/ZIP <br /> CONTRACTOR /C//l%�/L/ / "� !` PHONE / /" <br /> e'- <br /> CONTRACTOR ADDRESS v! t� ��L -�- __ CITY/STATE/ZIP c✓ / /�'� �� <br /> SUBCONTRACTOR / �f� I��i`L�_ _ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 a 61 D 09 Other NUMBER_t''(A`'V EXPIRATION DATE I ')l - <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private L Irrigation/Agricultural Ci Industrial J Water Quality Monitoring U Soil Sampling/Characterization <br /> 1 Public Water System <br /> -------C— <br /> If different from Owner: Water System Nameact Name or Phone Number <br /> TYPE OF WORK <Replacement Well ❑ Well Alteration/Modification f-I Other <br /> #of borings 4 of borings <br /> Monitoring Well(s) #of wells 0 Soil Boring(s) — Geotechnical <br /> Cl Out-Of-Service Well Ll Out-Of-Service Well Renewal 1_1 Cross-Connection Repair <br /> )ONew Pump Pump Replacement ❑ Pump Repair I Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method/ lud Rotary C Air Rotary i Auger [..i Cable Tool CI Push Point [I Other <br /> Proposed WellDepth _ft Excavation 42 in diameter i7 Open Bottom ravel Pack/Gravel Size �� '~ in diameter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter V/1- in Thic ess/Gauge/ASTM Sched _ - z� 'I Steel�lastic 1-1, Stainless Steel 0 Other <br /> Grout Seal Depth_ i Neat Cement(94 Ib bag/5-10 gat water) and Cement A/7c sack mix/7 gal water <br /> I Bentonite(20%solids) I I Other <br /> Grout Placement Method Limped .-I Free Fall i- Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Ll Driller Pump Contractor LI Other <br /> Concrete Pedestal Dimensions:Width ft Length It Thick in Christy Box 1 Stove Pipe <br /> PUMP ubmersibleI Turbine I' Other HP Pump SetLa ft Standing Water Level R 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS PE SATION LAWS. <br /> MI 4 UP CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209) 95 -76 7 <br /> SIGNED %�Z- TITLE_ z 7I DATE 3l <br /> . s <br /> At <br /> 7-1 <br /> PA <br /> rT <br /> O <br /> 5 <br /> E <br /> C <br /> G q AQ <br /> Z G 1 1 <br /> D PARTMENT US ONLY <br /> Application Accepted B � Date=4-�t_ .� / Area Employee ID# <br /> Grout Inspection B _ Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date �L� �21��ZCi� ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By CashRemitted Service Request# <br /> I "WZQ -�cS7/ -7S- <br /> � � � <br /> v 3 <br /> 5 iLpoi5 -7 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />