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�d a r ! A�� s. <br /> WELUPU P PERMIT� <br /> 3. ez <br /> j`,i11 JOAQUIN COUNTY CNVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NrjN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIR S 1 YEAR FROM DATE ISSUED <br /> f f In <br /> JOB ADDRESS �• �W ��tl� CITY2IP SZD m <br /> a <br /> CROSS STREE APNO I'S 3 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME g/`'G.L PHONE-7 y/ - ` I S N <br /> u <br /> n <br /> OWNER ADDRESS ^� CITY/STATE/ZIP -//72 _50 <br /> CONTRACTOR V Boss 4 , /� /' PHONE j���� ` t, <br /> CONTRACTOR ADDRESS � ( � CITY/STATE/ZIP 4/PHV�,�Mo*4 a,4 <br /> SUBCONTRACTORS x6/►-C &, -0 <br /> PHONE <br /> ��� ✓-0 ` <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP r^� <br /> LICENSE ��+-57 ❑ C-61 D-09 Other NUMBER ( EXPIRATION DATE �V 1-7 - G-jo <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE L 1 Domestic/Private >4rrigation/Agricultural i Industrial ❑ Water Quality Monitoring i-1 Soil Sampling/Characteffzation <br /> ❑ Public Water System_ _ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK �-<New Well iaMeplacement Well ❑ Well Alteration/Modification i I Other <br /> I Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings i Geotechnical #of borings <br /> i Out-Of-Service Well ❑ Out-Of-Service Well Renewal i i Cross-Connection Repair <br /> =New Pump i Pump Replacement ❑ Pump Repair i i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method.�Mud Rotary i i Air Rotary Auger D Cable Tool i Push Point i Other <br /> Proposed Well Depth-4 ft Excavation / 6 in diameter Open Bottom 9fravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameterl,� in Thickness/Gauge/ASTM Sched2.X_-) i SteelPlastic i Stainless Steel i i Other <br /> Grout Seal Depth So I ft 1 Neat Cement(94 lb bag/5-10 gal water) Band Cement ld. sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method [+J' %mped , Free Fall Other Retardant/Accelerator(name). <br /> PEDESTAL Installed By ;-<f briller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width z ft Length ft Thick in i Christy Box I Stove Pipe <br /> PUMP ,Submersible Turbine Other HP L Pump Set ft Standing Water Level ft <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 W!TH THE CALIFORNIA COf4TRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIN)OWM,24 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209))+953-7697 <br /> SIGNED qtr- TITLE(7Cr/r- DATE <br /> L <br /> ° <br /> Argo <br /> y I <br /> 00,10, <br /> j — T' 1 —9 T <br /> D€ PARTMENT U E )ON LY <br /> Application Accepted Date Area-- E Employee ID# <br /> Grout Inspection B Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 06 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 69 ➢� X41 I --�)0 -!5e�7SDI(p w�o�3�o JI <br /> v <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />