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V14 1E LLlPUPv1iP PEFRPA�u <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL I'IEALTI-I DEPT '1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> "JQ[f P _ f rn <br /> JOB ADDRESS c2{!J J 3 � �� ^��j✓YI!/-� � CITY/ZIP�'43: �� "-/q 9� 30`7 <br /> CROSS STREET_/iv /{S 2d /�-02V-61,2;2- PARCEL SIZE / 3 LAND USE APPLICATION# O rn <br /> OWNER PIANIE1.ed�/� �,���GJG2 PMONE <br /> OWNER:-' / <br /> IDDRESS .G�J7f'}ry j j�� `leeio2z C1TY(STATEI7-IP ��fu�� G� Gf 5 3d y <br /> CONTRACTOR PHONE 2 � <br /> CONTRACTOR ADDRESS� � Y/l�i�l��i�y CITY/STATE/ZIP�/J�!/�/f��//�zS <br /> �J,.� <br /> SUBCONTRACTOR PI-IONS pu/-� <br /> SUBCONTRACTOR ADDRESS CIT','/STATE/ZIP <br /> LICENSE C-57 ❑ C-GI ❑ D-09 ❑ Other NUMBER E)CPIRATION DATE el 3/^Zo 20 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE K Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water Systern <br /> If different from Owner: water System Name on ac'Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/ModificationOther vl i <br /> #of orings #of borings <br /> ❑ Monitoring Well(s) ;q of wells ❑ Soil Boring(s) ❑ Geotechnical qy <br /> 4-11 <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ^ I�71 <br /> 0 New Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well Casingyr �h <br /> WELL CONSTRUCTION Mq p p V <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑Auger ❑ Cable Tool 0 Push Point ❑ Other ��``11//f� �1 O,0 <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom El Gravel PacldGravel Size� te``r <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth it HBqLR0NAV N�. <br /> IAL <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel 11 Other TN SEP �N <br /> Grout Seal -Depth ft ❑ Neat Cement(94 Ib bag/5-90 gal water) ❑ Sand Cement sack mix/7 gal water NT <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PLINIP k Submersible Turbine ❑ Other I-IP Pump Set It `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 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 COMPENS 10 WS. A�{i�j <br /> MINIMUM R VANCE NOTICE REQUIRED FOR INSPECTIONS 2 g <br /> SIGNED L' TITLE S�CIr�/�f DATE <br /> EPAR T MENT U E ONLY <br /> Application Accepted fay Date f q Arca Employee ID# <br /> Grout Inspection By Rj Date //,, �r SPECIAL Well Permit <br /> Pump Inspection By Date�1/u fl�����"( WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ii: <br /> COMMENTS <br /> PE Sc Received hecL4/ Amount Permit/ <br /> Codes Info By as Remitted Date Service Request#' Invoice# Well ID# <br /> v 051 29- 6167 I iq htPW31q-�v <br /> EI-ID 43-06 WELL/PUMP PERMIT <br /> 8104/08 <br />