Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />MUn-MittUNUAt3Lt rtKM.I ( ��1,ALL [Uy V0,5 -/by/ FUR LAl'IKtJ l TEAR FROM DATE ISSUED <br />m <br />Joe ADDRESS —Ak�AH a-CITY/zi <br />p Pon A`5)�P (o <br />CROSS STREET ��//�� - /^A,,t�P N�y�y1� /�1��j '''1010 �1I PARCEL SIZE AND USE/APPLIC/A�TIO�Nl# I _ ' A <br />OWNER NAME T ` CCk-1 VW V,G PHONE l2li_\)'4 U/ QAp C—JG <br />OWNER ADDRESS O CITY/STATE/ZJP_SAO lj \ 2.01 <br />1 <br />CONTRACTOR �' PHONE -SyG�.��J^e'1) Lt <br />CONTRACTOR ADDRESS /�CITY/STATE/71P1(°w A <br />SUBCONTRACTOR N IIPHONE Lf', <br />ADDRESS rJ 1 n CITY/STATE/LP N <br />57 Y-61 D-09 II Other NUMBER 2�5 e 1 ExPtRAnoN <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Renue Section <br />WENDED USE Omestic/Private i Irrigation/Agricultural I Industrial ❑ Water Quality Monitoring i Soil Sampling/Characterization <br />❑ Public Water System <br />If different from OwnerWater System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well I Well Alieration/Modlficatlon i Other <br />1 Monitoring Well(s) # of Wells Soil Boring(s) # of bonngs i i Geotechnical >F of borings <br />❑ Out -Of -Service Well Out -Of -Service Well Renewal I Cross -Connection Repair <br />❑ New Pump (Pump Replacement Pump Repair I Raise Well Casino <br />Drilling Method Mud Rotary i Air Rotary I Auger Cable Tool - Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom 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 Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack mW7 gal water <br />i Bentonite (20% solids) Other <br />Grout Placement Method -1 Pumped Free Fall i Other i Retardant / Accelerator (name) <br />PEDESTAL Installed By I i Driller Pump Contractor -1 Other <br />i' Concrete Pedestal "Dimensions: Width ft Length ft Thick in i Christy Box i Stove Pipe <br />PUMP .Submersible:. i Turbine I Other HP I Pump Set 00 ft Standing Water Level kolt 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 />Io•\3\1 <br />101 G,OtWlication Accepted By <br />S� y0 'Q Ae kF- Grout Inspection By <br />NTH pE?AP' Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />RTMENT USE ONL) <br />Date <br />Date YY <br />Date °✓ �1 •� <br />Date <br />Areae Employee ID# <br />VVVI SPECIAL Well Permit <br />I WAIVER Received <br />Constructed Well Depth <br />N <br />D <br />O <br />M <br />w <br />e <br />1 <br />3 am, <br />'�EAJ 4L HEALTri <br />VW J <br />it <br />PE Sc Received Chec <br />Codes Info B <br />Amount <br />emitted <br />Permit/ <br />Date Service Re uest # Invoice # <br />Well ID# <br />.z F? / 9- <br />476 / I <br />11 S 00 0 ( <br />0 P003011,PJl <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />