Laserfiche WebLink
'19.259 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT I:ALL (LU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 16 4 2 9 1Cr,TPTC)m COURT CITY/ZIP S TOCKTON 95206 <br />CROSSSTREETBTWN BON .TTT & CAT.ptAC 1 $q_2'�/J-028 PARCEL SIZE 'L6gUSEAPPLICATfON# <br />OWNER NAME ��� PHONE 209 608-7335 <br />OWNER ADDRESS O CITY/STATE/ZIP Q KION CA 9 5 2 9 6 <br />CONTRACTOR Delta P= _.qTnCxmnN ARMAT iRP & MOTOR WORKS EAQ. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C C-57 X C-61 0 D-09 0 Other NUMBER 724778 EXPIRATIONDATE 08/11 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y___ Townshin Ranae Sa'rh.. <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: ater ys em ame Gonect Name or Hhone Number <br />..wmr` u rvew "ell a mepiacement well ❑ well Alteration/Modification 0 Other <br />G Monitoring Well(s) # of wells O Soil Boring(s) # of borings # of borings <br />u Geotechnical <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />❑ New Pump XBump Replacement ❑ Pump Repair 0 Raise Well Casino <br />Drilling Method C Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool C Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter „ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft C Neat Cement (94 Ib ba9/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) C Other <br />Grout Placement Method ❑ Pumped C Free Fall 0 Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP & Submersible❑ Turbine C Other HP ___J_ Pump Set 1 A 2 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 COMPENSATIO <br />MINIMU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CEO <br />DATE 3/6/2017 <br />1 <br />M <br />A <br />0 <br />0 <br />A <br />m <br />Application Accepted Sly <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Ty <br />TMENT USE ONLY <br />Date Area '��-- Employee ID#���� <br />Date SPECIAL Well Permit <br />Date t WAIVER Received <br />Date Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />a <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />s� <br />a8�l <br />`� g <br />0rt-� 7� , <br />DoAI-7 <br />8/04108 V� WELL /PUMP PERMIT <br />