Laserfiche WebLink
0 <br />, 9;Zef <br />*1 '4'11PU�C.L\ I1 -1a -1b 05^ <br />3` WELUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />SAN <br />HE <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />X�lkIII, <br />JOB ADDRESS �. `�_" '-' I H W r " � G� <br />CITY21P L I( e Y 1 1 `J' , 3, <br />CROSS STREET I� �� l I1� ) IRV APN In � --%' A L-� A,R�ICEL SIZE �1'/-TAND USE APPLICATION # -7 �-^ <br />OWNER NAME _ I , /l Cr�FHO`NEL�Ii� /- Ir�I l.� <br />OWNER ADDRESS J V C"� I (�'�I� D CITY/STATE/ZIP ''G ]"I S �1C.�� <br />CONTRACTOR G I I e y 1- J f V I �QI �(i r� PHONE 3 VI q 7 7 i1 <br />CONTRACTOR ADDREss P. C �� c x l a c"isTATEar c( 1 V I CA 61 `5 4: <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STAUTE/LP <br />LICENSE C-57 C-61 _ D-09 _ Other NuMBER' <br />i�j J2 •7 E1rPIRAnoN DATE -'7 - I <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE - DomesddPrivate 'yL Irrigation/Agricultural 7 Industrial = Water Quality Monitoring - Soil Sampling/Characterization <br />Public Water System <br />It dnerent 6om owner. r system Nam nrnoi Remii w Mone <br />Rumum <br />TYPE OF WORK New Well Replacement Well - Well AlteratioNModification - Other <br />Monitoring Wel(s) i of wells - Soil Boring(s) • or borings _ Geotechnical # or borings <br />Out -Of -Service Well - Out -Of -Service Well Renewal - Cross -Connection Repair <br />New <br />Drilling Method Mud Rotary - Air Rotary - Auger -- Cable Tool - Push Point - Other - ---------I /d <br />Proposed Well Depth 5(-y R E cavation J_ in diameter Open Bottom Y Gravel Pack/Gravel Size` diameter <br />ConductorCasing in diameter / Conductor Casing Depth ft <br />/ <br />Well Casing Diameter � in Thickness/Gauge/ASTM Schad L�' - Steel )k Plastic - Stainless Steel _. Other <br />Grout Seal Depth S[% R = Neal Cement (94 Ib bag/5-10 gal water) Sand Cement C sack mix/7 gal water <br />-j Bentonite (20% solids) _ Other <br />Grout Placement Method )(Pumped Free Fall Other _ Retardant /Accelerator (name) <br />PEDESTAL Installed By�i Driller Pump Contractor v - Other <br />Concrete edestal Dimensions: Width 7 ft Length R Thick in Christy Box Stove Pipe <br />uM ulxnerside - Turbine Other HP= Pump Set R Standing Water Level —L7,S-L R <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. 1 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 />L11MINIJU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />A <br />Application Accepted Date— <br />Grout Inspect B�' fff�p Date <br />Pump Inspection By Datet <br />Soil Boring Inspection By Date <br />COMMENTS N J A <br />EHO 43-00 <br />10 <br />b. <br />Area "Lr Employee ID#f� <br />SPECIAL Well Pertttit <br />WAIVER Received <br />Constructed Well Depth It <br /># 1 Invoice # Well ID# <br />00. <br />WELL (PUMP PERMIT <br />