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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT '1868 Cast 1-lazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> 11,10WREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> En <br /> _ Cm/ZIP IJOBHDDRE95 �� & <br /> (.ROssSTREEr UAL-VOLRIt _ -2-m- `6 PARCELSIZE LAND <br /> rAC0NDNU+S•�E APPLICATION# <br /> IOZ�7 o/G✓� <br /> � Db <br /> OWNER NAME �1Moh1e.r•_aM,)S1 LP PHONE 1$3� 5?SIV47 y' <br /> OWNER:?DDRESS )(1�,Z(p-�S. Oy I Qr IYr CITYISTATEIZIP I�,ni l�o�•� �. � <br /> CONTRACTOR ,V, �/1..Jl' ! l r••�� PHONE 52P <br /> CONTRACTOR ADDRESS I I s CITY/STATE/ZIP Mlgde #a _C�, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 0 C-61 0 D-09 D Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL(PIFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE 0 Dornestic/Private^Irrigation/Agricultural 0 Industrial (I Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If dlHerent from Owner. ser ys em Name on c eme or one Number <br /> -11;PE OF WORK XNew Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 of borings iF of borings <br /> 0 Monitoring Well(s) #of wells 0 Soil Borings) 0 Geotechnical <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> 'PIELL CONSTRUCTION <br /> Drilling illethod KMud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth 2 ft Excavation I Y In diameter 0 Open Bottom Gravel PacIdGravel Size In diameter <br /> 0 Conductor Casing In diameter / Conductor Casing Depth ft <br /> UUoil Casing Diameter_L in Thlcl<ness/Gauge/ASTM Schad —2,0 1 0 Steel KPlastiC 0 Stainless Steel 0 Other <br /> Grout Seal Depth JAC ft 0 Neat Cement(94 lb bao-10 gal water) 0 Sand Coment sack m/x/7 gal water <br /> Bentonite(20%solids) 0 Other <br /> Grout Placement Method Kpumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length It Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible0 Turbine '0 Other HP Pump Set ft `Standing Water Level ft <br /> 11-IEREGY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIN 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.l AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 1 MINIMUM 24 HOUR ADVANCE NOTICE(REQUIRED FOR INSPECTIONS <br /> '�^pA� J p <br /> SIGNED J1f ►r &A.&A TITLE D>^,16 -DATE <br /> S J UN O <br /> Ell I <br /> ARTMENT UIE4 <br /> NLYApplication Accepted By ✓ Datei Area—1 Employee ID#/� <br /> Grout Inspection By Date SPE IAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> 'JI�f t •Milt L4 Ill. r lL!+I <br /> PESC Received Checic#I Amount PermiU Invoice# Well ID# <br /> Codes to Into By Caph Remitted Service Re uest# <br /> WELL/PUMP PERMIT <br /> EHD 43-00 <br /> 0/04/00 <br />