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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202.(209)468-3420 <br /> NON-REFUNDABLE PERMIT GAIL.d2{)�)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> �QgbQ y <br /> JOB DDRESs Lower Sacramento Rd and Pixley Slough C,Tr/ZIP Stockton L <br /> n <br /> Eight CROSS STREET g Mile Rd APIA PARCELSIZE -y- G <br /> LAND USE APPLICATION# <br /> OWNER NAME _City of Stockton <br /> PHONE 209-937-8212 v, <br /> OWNER ADDRESS 425 N. E1 Dorado Street CITYISTATE/ZIP Stockton, CA 95202 <br /> CONTRACTOR Blackburn Consulting PHONE 209-522-6273 <br /> CONTRACTOR ADDRESS 4622 Glass Court, Suite A CITY/STATE2IP Modesto, CA. 95356 <br /> Precision Sampling <br /> SUBCONTRACTOR PHONE 209-465-8712 <br /> SUBCONTRACTOR ADDRESS 2365 Wigwam Drive CITYfSTATE/ZIP Stockton, CA. 9520 <br /> h5 <br /> LICENSE M C-57 C-61 D-09 :Other -7NUMBER T} ExPIRATION DATE +„1 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township— Range $eCtiOn ! <br /> INTENDED USE :. Domestic/Private `':Irrigation/Agricultural `:Industrial <br /> -Water QLIallly Monitoring 1 Soil Sampling/Characterization <br /> Public Water System <br /> Irdi(lurenl from Owner, aver ys em uonlaa Name or Phone Num r <br /> TYPE OF WORK New Well _Replacement Well ..Well Alteration/Modification Other �. <br /> Monitoring Well(s) #of veils I <br /> Soil BoringR of borings <br /> Boring(s) gr Geotechnical 4 olborinps <br /> ;Out-Of-Service Well C Out-Of-Service Well Renewal r_CrosS-Connection Repair <br /> New Pum ','.',..PumR Replacement -.Pump Repair C, <br /> WELL CONSTRUCTION <br /> Drilling Method rg Mud Rotary :i Air Rotary .S Auger :;Cable Tool D Push Point C Other <br /> — --- Proposed Well 2 Borings to 50' 2 Soring8 to 5'Well Casing _ V: <br /> Grout Seal Depth 50 ft &Neat Cement.(94lb bag/5-10 gal wafer) D Sand Cement sack mix.R gal water A <br /> Bentonite(20%solids) '_Other n <br /> ,Grout Placement Method Pumped ;;Free Fall !OtherTremmie .. RelardanUAccelerator(name) <br /> PEDESTAL Installed By --'Driller ^Pump Contractor 0Other <br /> Concrete Pedestal Dimensions:Width —ft Length ft Thick in D Christy Box J Stove Pipe ) <br /> i <br /> j PUMP 3 Submersible:;Turbine C Other HP 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 ,�fl <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL C <br /> WORKERS COMPENSATION LAWS. <br /> p,j`j M 1{1Ar.,/l's",,,2+4 HOUR ADVANCE NOTICE RE UIRED FOR iNSP C`IONS <br /> SIGNED /--�".4"'r....`# S ..G" o[' -s�'` TITLE M•P DATE 3 . 10 . 08 <br /> —I 777 <br /> n <br /> ) <br /> r <br /> I <br /> r <br /> n <br /> E1 <br /> rt <br /> I I <br /> A R T _ > ^�i L Y <br /> nn < <br /> Application Accepted By Date fJ� � Area Employee ID# <br /> Grout Inspection By '� Date � L SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By ._ Date Constructed Wel)Depth ft <br /> COMMENTS <br /> PE SC Received Check#f Amount Data Permit/ Invoice# WeIIID# <br /> Codes Info B Cash Remitted Service Request# <br /> fiq2 310151 S3s <br /> EHDV-06 <br /> L4'r <br /> erWS'L-PUMP PERMIT <br />