Laserfiche WebLink
• <br /> WELL/PUMP PERMIT - <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABL PERMIT CALL 209 953-7697 FOR(INSPECTIONS EXPIRES 1 YE DATE ISSUED <br /> LO <br /> JOB ADDRcss •- CmZ °1 <br /> � tl�� 0 <br /> CROSS STREET l C APN CATFLQ '030 1 J PARCEL SIE I. I b LAND USE A71CATION# �/I m <br /> OWNER NAME I (4 l( It ir�- �/,,.� I /PHO�N�E/j //1�/� ' / �/} o N <br /> OWNER ADDRESS p`— " ' • r/^' ! 1/9"T ATE/L t to(/�/1 t,✓1 <br /> CONTRACTOR '1 S II C I' 1�I 1 C l'._yPI.M{O7NE U <br /> CONTRACTOR ADDRESS �r/1� " C / T ./L V D <br /> SUBCONTRACTOR IV In /) PHONE, <br /> SUBCONTRACTOR ADDRESS' <br /> /p- CITY/STATE(LfP /I(tV) <br /> LICENSE D-S7 ✓ (;-6l 0.09 Other_ NUMBER ExPIRATON DATE <br /> GEOGRAPHICAL INFO ATION: Coordinates X Y Township_ Range Section v ` <br /> INTENDED USE V Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public WaterSystem <br /> If different from Owner Water System Name L;ontaCt Name or Phone Number C <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) 9 of borings Geotechnical #Of bo"nge <br /> ^u!-Ot-Sen-I:.�WeM Ouc-)f-S,,rvice\'Je!l Renewal Cross-Connection Repair <br /> New Pump Purn2 Re iacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other O <br /> Proposed Well Depth it Excavation in diameter Open Bottom Gravel Pack/Gravel Size In diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other r <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other _ <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> (PEDESTAL Installed By Driller Pump Contractor Other — <br /> Concrete Pedestal Dimensions:Width it Len h ft Thick in Christy Box . Stove Pipe �{ <br /> IP Submersible Turbine Other HP Pump Setft Standing Water Level ft <br /> IHEREBY 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 /> MINIMU 4 H/(((���]]]��qAJ AD E NOTICE REQUIRED FCR INSPECTIO,N-,Sri-PLEASE CALL(209 -77697 � <br /> SIGNED." '` TITLE"/r) II Y,1 C G� I DATE L- <br /> I ' n <br /> cl 1 <br /> �N <br /> V <br /> =9 13 <br /> PAYME �Ep 2016 <br /> --- --- Ei. I I <br /> �ECEiV <br /> ��P ®� RCh'°L4ENTAL HEALTH <br /> SA'`I J0►.QUt <br /> ERMiT�ERWCES <br /> E WV1RD H <br /> µKA�rNOEPARTM� P TMENT UJ $E pyLY <br /> Application Accepted By_ '/�/ to � Area Employee ID# <br /> Grout Inspection By rt DNte _ SPECIAL Well Permit <br /> Pump Inspection By ej U I yyER Received <br /> Soil Boning Inspection By • Date Constructed ell Depth ft <br /> COMMENTS tri/L' r ,i?.� t',--tom !... �i.Lel(- li"s r: ". :7 (7- <br /> PE <br /> ZPE SC Received hec Amount Date Permit] Invoice III Well ID# <br /> I Codes Info B Remitted Service Request# <br /> X13 0, o <br /> EHC=SOF WELL(PUMP PERMIT <br /> u3b 12 <br />