Laserfiche WebLink
WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"o FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V±l. CITY/ZIP �" OLTcs 1�.: 1 c�-l' — <br /> h <br /> CROSS STREET N LA9-L,(9 4', S T' APN PARCEL SIZE[OO LAND USE APPLICATION# <br /> OWNERNAME M % -L A <br /> PHONE <br /> '/�/ ,� fi <br /> OWNER ADDRESS r 2. CITYI$TATEIZIP <br /> �� �f ti��� G <br /> CONTRACTOR <br /> t Ctl_- C-), t <br /> , At t)&yLe0rj ` 14 S(3+ 1101-T%=S PHONE <br /> CONTRACTOR ADDRESS CITYIS FJZI L D I CFA 2`f O <br /> 0i � <br /> SUBCONTRACTOR e�-H <br /> SUBCONTRACTOR ADDRESS CITVISTA TF <br /> "Pi 14 <br /> houCI TION ATE <br /> 8/C57 ❑C-6l ❑D-09 ❑Other NUMBER 6 <br /> LICENSE r� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Tory rm <br /> $ <br /> INTENDED USE ❑DQmesticlPrivate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring o 1 l tze{ atian <br /> Cl Public Water System Contact Name or rn0ne INUMDCT <br /> if different from Owner. Water System Name <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Moddii-fication E3 Other <br /> b of honngs ❑Geotechnical a of tiorings r. <br /> ❑Monitoring Wells) #of wells Soil Boring(s) <br /> ❑Out-Of-Seryice Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION r <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other I <br /> Proposed Well Depth -*,S ft Excavation in diameter ❑Open Bottom ❑Gravel Pack f Gravel Size in diameter <br /> Conductor Casing in diametcr i Conductor Casing Depth ft V ; <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth FALft `'Meat Cement(94 lb bad✓5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted - <br /> Grout Placement Method ❑Pumped IR Free Fall ❑Other 0 Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ,�y] Other <br /> Concrete Pedestal Dimensions:Width N / Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M1I 24 HOUR E NOTICE/REQUIRED FOR INSPECTIONS ^] <br /> SIGNED TITLE / / DATE (� <br /> I <br /> 4 <br /> t <br /> A T �- <br /> � pR <br /> PARTMENT U E O �1LY <br /> Application Accepted Bype���E <br /> Date A Area Employee 1D# <br /> Grout Inspection By �/z t r''^1 Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date © WAIVER Received <br /> Constructed Well Depth It <br /> COMMEN S ►lj <br /> a <br /> PE 11 SC Received Chec Amount Date Permit] nvoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> WELL PUMP PERMIT <br /> EHD 43-02-001 <br /> 1127(2005 <br />