Laserfiche WebLink
RECEIVED <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT lass EAST HAZELToN AvENUE-STOCKTON CA 95205-(209)46a*y 0 9 2010qp <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �5 C 41111 A1yc /-- �ITrmPrnnyn'1i4.�i c� ENVIRO NTALHEALTH <br /> GeosS srREETS ion A " l'^1✓ APN /71��L 10 { !/PARCEL 512E��O LAND 416E APPLICATION# PER IM SERVICES <br /> �,V `j D n.- <br /> OuwER NAME PHONE <br /> OMER ADDRESS /�/� � �I►•r r ! �e �! 1 CITYISTATE/LP MA n-f&_14 !�4 <br /> 4'. <br /> �lii <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS CITVISTATEZP /� . � <br /> SUBCONTRACTOR PHONE ^— <br /> SUBCONTRACTOR ADDRESS — CTTYISTATEMP <br /> LICENSE []C-57 1 []B-09 []Other NUMBER 2 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)Ll Arsenic(4393) <br /> INTENDED USE . Domestic/Private []Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring []Soil Sampling/Characteri2ation <br /> []Public Water System <br /> M different from Owns_ Nater System Name Cordact Name a Phone Nmbw <br /> TYPE OF WORK []New Well []Replacement Well D Well Aaeration/Modification D Other <br /> []Monitoring Well(s) #of wells D Soil Borings) "b—O' []Geotechnical n of bwngs <br /> ❑Out-Of-Service Wel D Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> w Pump []Pump Replacement 0 Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary []Air Rotary D Auger D Cable Tool []Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched D Steel D Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth ft []Neat Cement(94 1b bag/5-10 gal water) ❑Sand Cement sack mixt gal water <br /> ❑Bentonite(20%solids) []Other <br /> Grout Placement Method []Pumped []Free Fall []Other []Retardant/Accelerator(name) <br /> PEDESTAL Installed By []Driller Cl Pump Contractor Ll Other <br /> 0 Concrete Pedestal[]Dimensions.Width ft Length ft Thick in []Christy Box []Stove Pipe <br /> PUMP ubmersible❑Turbine D Other HP Pump Set v ft Standing Water Level ft <br /> I HEREBY CER FY 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 COMP SA TI LAWS. <br /> MI PUR ADVANCE NOTICE REQUIRED FOR II/N PIEECC/TIII PLEASE CALL(209)953 6 7 <br /> SIGNED TITLE DATE <br /> R gyk, <br /> �cFiv or <br /> MAy10 ?0 <br /> oqa�/ 18 <br /> N <br /> tipF,;At <br /> FNT <br /> EP RTMENT US <br /> - <br /> Application Accepted By ` Date Area Employee IDP 6t <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received ec Amount Date <br /> Perm*U Invoice# Well <br /> OX <br /> CodAs Info emitted Service Re uest# <br /> 91041A6 rprised 41/4/18 WELL RUMP PERMIT <br />