Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209)468-3420 <br />NON-REFUNDABLE PERI MIT CALL <br />`LL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS -}- I I1-11 ,,�05 / �7 �j1NY I� CITY/ZIP YJfi rA 01W <br />CROSS STREET t r C� T ✓'C \C1 Yom{ I� V A W��� O� PARCEL SIZEI-I-O—LAND USE APPLICATION <br />OWNER NAME T-rr�1 I I�(iPH�ONE <br />`J� 1�A' <br />OWNER ADDRESS \ VI p� L" `",/ Z' CITYISTATEILP w LLL(/] -,,L (�5] <br />CONTRACTOR 1I� 1_ L ( /V I I PHONE <br />1 <br />CONTRACTOR ADDRESS CITY/STATE/LP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATEIZIPP Q <br />LICENSE C•57 X C-61 D-09 Other NUMBER EXPIRATION DATE ' V <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE y(DomesticJPrivate = Irrigation/Agricultural � Industrial Water Quality Monitoring Soil Sampfing/Characterization <br />.-I Public Water System <br />If different from Owner. Water System Nam CoMad Nam or Phone NUMbef <br />TYPE OF WORK KNew Well - Replacement Well = Well AlterationlModification C Other <br />Monitoring Well(s) # of wells S Soil Boring(s) If of borings - Geotechnical It of borings <br />Out -Of -Service Well - Out -Of -Service Well Renewal Cross -Connection Repair <br />'/New Pumn Pumo Reolacement - Pumo ReDair Raise Well Casina <br />Drilling Method i\ Mud Rotary _ Air Rotary Auger Cable Tool - Push Point Other _ <br />Proposed Well Depth 3W5 It Excavation in diameter - Open Bottom X' Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / ConduCcto�r Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched_ Steel � Plastic Stainless Steel I- Other <br />Grout Seal Depth ft _ Neat Cement (94 lb bag/5-10 gal water) Sand Cement I ti .3 sack mW7 gal water <br />Bentonite (20% solids) _ Other <br />Grout Placement Method- umped _ Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller _ Pump ConIla Other <br />oncrete Pedestal r Dimensions:; h ft Length ft Thick n Christy Box -Stove Pipe <br />PUMPy 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 F INSPECTIONS. PLEASE CALL (209) 953-7697 <br />��7- � -- :; c�J <br />SIGNED L�1-c'� TITLE �I DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By ( Date CA l <br />Grout Inspection By IL -Date r� <br />Pump Inspection By Date r <br />V u <br />Soil Boring InsPp5 Ion By Date — <br />COMMENTS e.ii... <br />a <br />*1 <br />!'\ . - 0 ONCE <br />� �°PQo ME �MENc <br />EN�NOEp <br />Area t> A I qi I Employee ION <br />7 SPECIAL Well Permit <br />J WAIVER Received <br />ConsWcted Well Depth ft <br />0-- Po.j <br />PE <br />Codes <br />SC Received <br />Info B <br />Chec Amount <br />Cash Remitted <br />Permit/ <br />Date Service Request # Invoice # Well ID# <br />i-�J <br />O� 3 <br />to to t1 !G)37 I -I <br />EHD 43-08 -lZ ?001-3 7q I1 WELL (PUMP PERMIT <br />4/30/12 43 <br />Wl <br />