Laserfiche WebLink
WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � IF, Cm dycy 2` - CITY21P <br /> CROSS STREET_ 9q APN �/ Z� PARCEL SIZE LAND USE APPLICATION# M <br /> N <br /> —wrNw �'Q/� N <br /> OWNER NAME � <br /> PHONF _a _�J(A{71 <br /> OWNER ADDRESS /CITY/STATE/ZIP 9 ''�// _ <br /> CONTRACTOR �I I.4/ �� ,J-f/�� PHONE L .— 24 t J-/ <br /> CONTRACTOR ADDRESS .9 (I)i IC4X Qa� CRY/STATE/ZIP'�. <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CI /STATE/ZIP <br /> LICENSE C-57 [1 C-61 n D-09 ❑ Othef NUMBER, EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section_ <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural D Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 11 Public Water System <br /> If different from Owner: Water System Name ontad eme or one um r <br /> TYPE OF WORK ❑ New Well ❑ Replacement Welt ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitodng Wells) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> XOut-Of-Service Well El Well Renewal [ICross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement D Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other <br /> Proposed Well Depth ft Excavation In diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size In diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth h <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic D Stainless Steel D Other <br /> Grout Seal Depth-ft Cl Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mW7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method D Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ri Pump Contractor ❑ Other <br /> Concrete Pedestal;.'Dimensions:Width ft Length ft Thick in ❑ Christy Box n Stove Pipe <br /> uMP I- Submersible❑ Turbine 1; Other HP Pump Set ft Standing Water Level fl <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 /> MU 24k,' UR ADVANCE NOTICE REQUIRED FO I §PdECTIONS-PLEASE CALL (209)9 3-76 7 <br /> SIGNED TITLE DATE I- <br /> 62 <br /> �r <br /> za <br /> W4 <br /> 5U <br /> O� <br /> >> <br /> zr <br /> W. <br /> I <br /> TMENT USE ONLY �/ <br /> Application Accepted B)� DEPARDa Z Area _ Employee ID# /� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS -- <br /> PE SC Received Check#/ Amount Date Permit( Invoice A Well ID# <br /> Codes Into B Cash Remitted Service Re uest# <br /> 7 > S 7G 1 12fZKv LSkO07 ti10 <br /> EHD 43.06 WELL/PUMP PERMIT <br />