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 /> N <br /> JOB ADDRESS Y CITY/ZIP r-A��� D <br /> / / 0 <br /> CROSS STREE ' APN QW77 l Q PARCEL SIZE l LAND USE <br /> /APPPLICATIION# <br /> ��Cn/ m <br /> _.. �.C)q-q `N/I ! /15 y <br /> OWNER NAME � PHON N <br /> OWNER ADDRESS CITY/STATE/ZIP Q <br /> CONTRACTOR V PHONE <br /> �l 151joyp <br /> CONTRACTOR ADDRESS N CITY/STATE/ZIP / D`�1 ! 53(� <br /> i f <br /> SUBCONTRACTOR _ PHONE <br /> Iln��( � <br /> SUBCONTRACTOR ADDRESS P TY/STATE2IP_ <br /> 1' / <br /> LICENSE C;d, C-57 C-61 ) D-09 U Other NUMBER ��. EXPIRATION DATE � l <br /> GEOGRAPHICAL INFOPMATION: Coordinates X Township Range Section <br /> INTENDED USE i'yDomestic/Private �: Irrigation/Agricultural U Industria HiloI <br /> tact I�/ racterization <br /> I Public Water System <br /> If different from Owner: Water System Name ontm or er <br /> remit Ma, <br /> TYPE OF WORK Replacement Well U Well AlteratlovMl?djfjggt In ❑ ^t r lau I 1 <br /> Monitoring Well(s) #of wells Soil Boring(s) K UUC g ftfpfe a IQk�np )-y ,,,� a°t borings <br /> 11 Out-Of-Service Well U Out-Of-Service I kAfflnme�f4p ,,ionft??p h, 1.� <br /> �, New Pum Pump Replacement ❑ Pump Repair I7 Raise Well Casing <br /> WELL CONSTRUC-A6N <br /> Drilling Method A Mud Rotary Ci Air Rotary 1, Auger U Cable Tool U Push Point U Other <br /> Proposed Well Depth 'e2-!j4—ft Excavation _�-2-' in diameter I Open Bottom Gravel Pack/Gravel Size f �i in diameter <br /> Li Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter�fl- in Thickness/Gauge/ASTM Sched tt�, ,� J Steel I Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth C 00 ft Neat Cement(94 lb bag/5-f0 gal water) ❑ Sand Cement 10. 37 sack mW7 gal water <br /> CI Bentonite(20%solids) I Other <br /> Grout Placement Method i I Pumped -I Free Fall - Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller Pump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in i-I Christy Box r-' Stove Pipe <br /> PUMP X Submersible!l Turbine I; OtherHP Pump Set ft 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 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINL1 LANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209) 953 769 <br /> SIGNED-- --- C �!J �� TITLE DATE l <br /> D <br /> l <br /> MT E VI 'E <br /> 77 <br /> M <br /> 1! AM-1 <br /> JAft I I' I I I I I <br /> Ln�inti n <br /> D P A R T M E N T USE ONLY <br /> r <br /> Application Accepted By- Date�./1_/Lb Area '7 Employee ID# 6 TO <br /> Grout Inspection By Date _ 0 SPECIAL Well Permit <br /> Pump Inspection By _____ Date U WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS O C- - T <br /> PE SC Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By u3snRemitted Service Request# <br /> 37� X37! 3�1°b q I(p s 0 5 cv <br /> P �3 _ 1 U -751P O <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />