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%s <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468.3420 <br /> NON-REF BLE PERMIT CALL 2DS)9953-76137 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS Eight Mile Rd and So�juyt�h Pacific/ RR CITY/ZIP Stockton �o <br /> CROSS STREET Pearson Road APNEIK! ( ARCEL SIZE LAND USE APPLICATION# 100 <br /> OWNER NAME City of Stockton PHONE 209-937-8212 iy <br /> OWNER ADDRESS 425 N. El. Dorado Street CITY/STATE/ZIP StocktoIl, CA 95202 <br /> CONTRACTOR Blackburn Consulting PHONE 209-522-6273 <br /> CONTRACTOR ADDRESS 4622 Glass Court, Suite-A CITYISTATE/ZIP Mode S to, CA. 95356 <br /> SUBCONTRACTOR precision Sampling _ PHONE 209-465-8712 ' <br /> SUBCONTRACTORAODRess 2365 Wigwam Drive9� <br /> CITYISTATTEIZIP Stockton, CA. 952 05 <br /> LICENSE ) C-57 /D-09 Other y4S �ICYJ� J <br /> '\\\ <br /> GEOGRAPHICAL INFORMATION: CoordinatesX Y Township_ Range Section_ <br /> INTENDED US Z DomestlGPriVate I Irrigation/AgriCUltural _Industrial -1 Water Quality Monitoring !SoilLSampling/C�haracteldlzatiojjPublic Water SystemII different from Orme,. one aone <br /> TYPE OF WORK 7.New Well Replacement Well 7. Well Alteration/Modification Other <br /> _Monitoring Weil(s) #Of Wells _Soil BOrin s uol cormos 12 X.ILorings ?(� <br /> 9O h;Geotechnical \ <br /> Out-Of-Service Well i- Out-01-Service Well Renewal Cross-Conneclion Repair <br /> New Pump Pump Replacement _ Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method -S Mud Rotary =1 Air Rotary G Auger Cable Tool Push Point D Other <br /> Proposed Well 1 Borings to 70' 2 Borings to Z,15' 2 Borings try l <br /> - -Borings-o 1 Vi` -f Fnsln - <br /> Well Casing 1 a <br /> i —---- -- <br /> ,�,,..,....... —.,J <br /> Grout Seal Depth 60-75 ft 9.Neal Cement(941b bag15-10 gal wafer) -Sand Cement y sack mixf7 gal water <br /> Gent o it (201%solids) ':I Other <br /> Grout PI-ac ementMethod = Pumped _!Free Fall Ll Other Tremmie J Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ED Pump Contractor D Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick In 0 Christy Box €:;Stove Pipe I <br /> PUMP J Submersible:-..Turbine u Other HP -..-ft <br /> TPump Set ft Standing Water Level <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 COMPENSATION LAWS. <br /> HNIM M 24 I"lO:3F;.ADVANCE NOTICE 1 Qi11El?e...L...7(((FOR INSPECTIONS n <br /> SIGNED TITLE DATE <br /> 3 • l 0 . 0 S <br /> k V <br /> T E O L / <br /> / -• .csy / <br /> Application Accepted B - ate �� t} Area1r/ <br /> Employee ID# <br /> Grout inspection By. Date S L SPECIAL Well Permit <br /> Pump Inspection By Date <br /> — WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount PermiU <br /> Codes Info By Cash Remittod Date Service Request# Invoice# Well ID# <br /> —- <br /> EH D 42-06 <br /> 912WO' WELL-PUMP PERmrr <br />