WP0037605 - Laserfiche WebLink

Home Browse Search

YY GLL./ C i.3MP Pi..IRMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 m8 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT — I" - JOB ADDRESS (� CROSS STREET OWNER NAME V OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE KC -57 I C-61 LL 12U91 953-7697 FOR INSPECTIONS tXP1KLb 1 YEAR FROM DATE ISSUED Pitt J 2 It �� CITY/ZIP LAr\K , f v \ � J Yr' AP D PARCEL SIZE •LAND USE APPLICATION # PHONE CITY/STATE/ZIP P HO NE � L� L CITY/STATE/ZIP PHONE ❑ D-09 ❑ Other CITY/STATE/ZIP NUMBE69 I V EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private - Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring I I Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well i Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair New Pum -I Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary I I Air Rotary -1 Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic i Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sackmix17 gal water _1 Bentonite (20% solids) ❑ Other Grout Placement Method � Pumped ❑ Free Fall LI Other I I Retardant / Accelerator (name) PEDESTAL Installed By 11 Driller ❑ Pump Contractor I Other ❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ri Christy Box Fii Stove Pipe PUMPSubmersible) I Turbine CI Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIF IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPE N LAWS. MUM 2 OUR ��Q�TICE REQUIRED FO CTIONS -PLEASE CALL (209) 953 7697 SIGNED TITLE �� DATE ( ( ' EP RTM ENT US ONLY Application Accepted By Date Grout Inspection By Date Pump Inspection By Date _� ZZ' Soil Boring Inspection By Da:(- rr)NAMFNTC Area Employee ID#Alo—KM ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth _ _ft ;r m m D 0 m m ch to PE SC Inffoo(� Received B Check#/ Cash Amount Remitted Date Permit/Codes Service Request # Invoice # Well ID# EHD 43-06 WELL /PUMP PERMIT 4/30/12