Laserfiche WebLink
33.06 /D'io-lls� <br /> • " 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 I -7 C I_l V-t J CITY/ZIP :ES-C-41411 '?S3210 m <br /> a <br /> v <br /> CROSS STREET APN 2H S 2-6 n- 1 3 PARCEL SIZE LAND USE APPLICATION# � <br /> p M <br /> OWNER NAME (,�--e.�r'4'-�C--_ -'e U-e 1 d e' PHONE -7 65-y gl,.55 <br /> t N <br /> OWNER ADDRESS 1._l_p_ � DOACIS - TO CITY/STATE2IP SC-« 0 ^• I CA g153Z0 <br /> CONTRACTOR o►S 1 (�• ' 1^�• PHONE Sum Z� <br /> CONTRACTOR ADDRESS )�r5 CITY/STATE/ZIP t ' K --S-fO r 6a %GJ3 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER b U�O Z z. EXPIRATION DATE q-30-/-7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private Irrigation/Agricultural `-1 Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well ❑ Well Alteration/Modification Other <br /> Monitoring Well(s) If of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement ❑ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger ❑ Cable Tool Push Point Other <br /> Proposed Well Depth _ft Excavation -Z in diameter � Open Bottom Gravel Pack/Gravel Sizein diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft �J3 <br /> Well Casing Diameter 1 in Thickness/Gauge/ASTM Sched 2 on Steellastic Stainless Steel Ceb 6 �'�NJT <br /> Grout Seal Depth /0:5 ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement sac jc r'-i; Qter <br /> )(Bentonite(20%solids) n Other NaR I a � <br /> Grout Placement Method`(Pumped Free Fall Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller X Pump Contractor Other kNt/f <br /> Concrete Pedestal, Dimensions:Width ft Length it Thick in I i Chris 1-1 tp <br /> PuMP Submersible Turbine Other HP Pump Set 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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-76697 6 / <br /> SIGNED ��- TITLE r-j ��" DATE Z- L I <br /> • •�;;<F' .Fri <br /> ` <br /> Mt.is rs. V w <br /> ::4 <br /> { <br /> #' 11-177.1. ----- —1_ 1 I I I 41 1 fl i I I I .► l �1, �r i.'•e ,. 1, <br /> DEPARTMENT USE ONLY <br /> App;icatfc,Acceptad 8, k�A Date 4 Area 2:mPk-yee <br /> Grout Inspection By s.. Date [I SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COM NTWak rrc 15err ti <br /> 6 3 l r see-nit <br /> PE SC ReceivedChec Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Ivo # e I <br /> EHD43-06 2,1;j,1,16 ­'0- <br /> `/�jw��� /V�� wC �5n rpGpQ34Lv�LfoC_ el_ I WELL/PUMP PERMIT <br /> 4/30/12 /� %� •Y"� �� � 'S•t�iQM'Y� �+'rT %f�� ( !/ l{4•l�J� <br /> owns w� � ��$i �,� .� e.-�,, iss.•��( S�t7yS <br />