Laserfiche WebLink
WELL/PUMP PERMIT i <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEQ4ATA—A NT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />A <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS) <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 " C-61 1 1 D-09 Other <br />C <br />GALL (ZU9) 9b3-16'9- /. FOR INSPECTIONS tAll'IlitZ�P 1 TEAR FRUM UAIL ISSUtU <br />r <br />1)I* Iti 1 Je � n CITY/ZIP tAA,&6y1 <br />APN �0 - :/ uPARCEL SIZE LAND USE APPLICATION # <br />J J0I1 PHONE <br />�l Q3 <br />tOvi )1V b -1 CITY/STATE/ZIP �� C,1() U J )(Q <br />HONE `VCia� / <br />r-�jQ��-• �%s s� <br />CITY/STATE/ZIP <br />PHONE <br />CITY/STATE/ZIP / , <br />NUMBER <3 11 I d 14c EXPIRATION DATE G 3o-1 <br />/' <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE Domestic/Private i Irrigation/Agricultural I Industrial Water Quality Monitoring Soil Sampling/Characterization <br />G Public WaterSystem <br />If different from Owner: Water System Name ontact Name or Phone Number <br />TYPE OF WORK I New Well I I Replacement Well I Well Alteration/Modification Other <br />1 Monitoring Well(s) # of wells I Soil Boring(s) n of borings Geotechnical <br />I; Out -Of -Service Well I I Out -Of -Service Well Renewal a Cross -Connection Repair <br />it of borings <br />X, New Pump I Pump Replacement I Pump Repair -I Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary I I Air Rotary Auger " Cable Tool i Push Point Other <br />Proposed Well Depth ft Excavation in diameter I i Open Bottom 1 1 Gravel Pack/Gravel Size in diameter <br />I , Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel I Plastic i I Stainless Steel i Other <br />Grout Seal Depth ft I Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) i Other <br />Grout Placement Method 1 i Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By 1 Driller I Pump Contractor i Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christv Box Stove Pipe <br />PUMP y Submersible Turbine Other HP f 7 Pump Set ((J% 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 WILES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA COljl-ACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENS WS. <br />M 24 UR ADV E CE REQUIRED FOR I CTIONS - PLEASE CALL (209) 953 697 <br />11 �� , <br />SIGNED TITLE hl= / DATE <br />DE ARTMENT JSE ONLY <br />Application Accepted By Date �b <br />Grout Inspection By Date <br />Pump Inspection Ry r Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Areaq4 qq Employee ID# Q <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth _ ft <br />N <br />4 <br />m <br />D <br />0 <br />0 <br />m <br />m <br />N <br />rn <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />o <br />31'�_g3 <br />�" <br /><< lb <br />LAJPd6 L3?& dI)L <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />