Laserfiche WebLink
' WELUPUMP PERMIT <br />SAN JOAQUIN 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 />JOB ADDRESS /-:' 2,2," WCITYRIP <br />CROSS STREET // !%1'L01V,_j 'MVel APN PARCEL SIZE AA41LAND USE APPLICATION # <br />OWNER NAME L't-,s o-4'4ZLL-Q4 " r _ PHONE _72? <br />OWNER ADDRESS 2O jjiyJCiQ1iiVIJIL01010d 4 CITY/STATE/ZIP /1/AIP14140� <br />CONTRACTOR mQ_ Sp //.3 Y�L I K.9 PHONE d L.L <br />CONTRACTOR ADDRESS -1 19_ 41 s IRJ CITY/STATE/ZIP 112 &' d4 ,0-o � �f <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE )(C-57 `) C-61 71 D-09 [1 Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 'h6+ EXPIRATION DATE - f/ / 7 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USEDomestic/Private F Irrigation/Agricultural ❑ Industrial Ci Water Quality Monitoring U Soil Sampling/Characterization <br />Cl Public Water System <br />If different from Owner: VVater System Name ontact Name or Phone Number <br />TYPE OF WORK New Well X Replacement Well ❑ Well Alteration/Modification FI Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />D Out -Of -Service Well U Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />F] New Pump -_' Pump Replacement ❑ Pump Repair 11 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ,-Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other <br />Proposed Well Depth If It Excavation /Z- in diameter ❑ Open Bottom 'Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter Thickness/Gauge/ASTM Sched Z-00 U Steel XPlastic C Stainless Steel ❑ Other <br />Grout Seal Dept It C i Neat Cement (94 lb bag/5-f0 gat water) ❑ Sand Cement sack mix/7 gal water <br />!Bentonite (20% solids) ! 1 Other <br />Grout Placement Method a Pumped i=1 Free Fall FI Other U Retardant / Accelerator (name) <br />(PEDESTAL Installed By ❑ Driller X Pump Contractor ❑ Other <br />Concrete Pedestal F. Dimensions: Width ft Length It Thick in 11 Christy Box U Stove Pipe <br />PUMP I-; Submersible[] Turbine I; Other HP Pump Set ft Standing Water Level ft <br />1 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 />MINIMUM 24 jH/O/UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED LL(,' `� TITLE DI"l/jeo DATE'3— 6_/ / ry <br />EPRTMENT US ONLY <br />7 <br />Application Accepted Date <br />Grout Inspection By _ nate (� <br />Pump Inspection By 1'v Date Y <br />Soil Boring Inspection Ely <br />N <br />1 <br />m <br />D <br />O <br />m <br />m <br />W <br />N <br />Area i Employee IDI4 —11jI/b <br />❑ PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well <br />ft <br />PE <br />Sc <br />Received <br />Amount <br />Date <br />Permit/ <br />Invoice # <br />KInc <br />Well <br />Codes <br />Info <br />B <br />ash <br />Remitted <br />Service Request # <br />wPOO 3)2-J25 <br />L3 <br />=, <br />I <br />i <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />