WP0037977 - Laserfiche WebLink

Home Browse Search

WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED A ,^ In JOB ADDRESS 4_'t''^1 CITY/ZIP ��'l 0 y , l��O f 0 CROSS STREET M� �w.} .j}AP�N^7 Z/,��/'�LOO-- IPARCEL SrLE��LAND USE ArP,PL�ICATION# / OWNER NAME / a /V 1 / `a'� ` ,I 1 VI,V I PHONE 2I!'� OWNER ADDRESS � -& CITY/STATE/ZIP CONTRACTOR '\t C1 1' " `"'� QV1 I I ONE 2 y_` -Vf LQ ' V CONTRACTOR ADDRESS I ✓1N 1 ' 4t A CITY/STATE/ZIP MQ C!--e&fn/rl if 7 SUBCONTRACTOR Y`� PHONE (/ l SUBCONTRACTOR ADDRESS Crry/STTATE/ZIP U J �� LICENSE C-57 L C-S1 U D-09 U Other NUMBERyl�(Q PIRATION DATE _` 4_l/t GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ INTENDED USE DOmestic/Private 7 Irrigation/Agricultural ❑Industrial J Water Quality Monitoring C Soil Sampling/Characterization U Public Water System If dlfferentfrom Owner. Water SYSterrl NSM Gontact NaMe or Phone NUMber TYPE OF WORK rew Well L Replacement Well U Well Alteration/Modification U Other Monitoring Well(s) #of wells ❑Soil Boring(s) #of bodogs D Geotechnical #of borings ❑Out-Of-Service Well U Out-0f-Service Well Renewal ❑Cross-Connection Repair U New Pump L Pump Replacement U Pump Repair U Raise Well Casing WELL CONSTRUCTION Drilling Methodud Rotary C Air Rotary C Auger 7 Cable Tool ❑Push Point ❑ Other Proposed Well epth��ft Excavation 2— in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter n Canduclor_Casing in diameter / Conductor Casing Depth It Well Casing Diameter 1 in Thickness/Gauge/ASTM Sched n Steel n Plastic n Stainless Steel -1Other Grout Seal Depth 1070 it C Neat Cement(94 111 bag/5-10 gal wafer) ❑Sand Cement sack mW7 gal water )(Bentonfte(20%solids) L Other Grout Placement Method Pumped D Free Fall C Other ❑Retardant/Accelerator(name) PEDESTAL Installed By :1 Driller C Pump Contractor :1 Other ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP U Submersible]Turbine C Other HP Pump Set ft Standing Water Level ft I HEREBY CE IFY HAT I HAVE REPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN C DINANCES AT LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AC I WITH CA FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WOR 0 PE S ION L U 4 REQUIRED FOR INS ECTIONS' LS CAL 4(20�)953- 697 ' SIGNE TITLE AVEp B 2 3 2018 AQUPmeftjvIN OIJIVTY AL MENT EP RTMENT LYSE N I 7f Y )��/�/� Application Accepted By Date !i Area T/ "/ 1 Employee ID Grout Inspection By Date 0 SPECIAL WBII Perlril1 Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth It COMMENTS PE Sc Received heck#/ Amount Date Permit/ Invoice# Well ID# Codes Info B emitted Service R uest# L� 112- 2123 -)P _? 77 EHO 43-06 WELL/PUMP PERMIT 4/30/12