Laserfiche WebLink
19888 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />2929 S. ST. RT. 99 W. FR.. CITY/ZIISTOCKTION C)5215 <br />T nnm T S APN 179-10-010 _PARCEL SIZE 2.9 5 LAND USE APPLICATION # <br />�OfYI'(A LI �! LLQ <br />OWNER NAME BTX F.XPRF.�� Kt�y �'��II CONTACT - CAR.0111 TA PHONE 630-766-7610 X 61 <br />SelisenvLU-e /4- tei)/a <br />OWNER ADDRESS 18 5 0 ARTHi1RRIS_ 42c'K SUpI`P-kQ L, CITY/STATE/ZIPELK ROVE VILLAGE., TT,T.60 <br />CONTRACTOR Delta Pump _STnCKTnN ARMATURE & MOTOR WORKS (EAQ.209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton CA 95203 m <br />-o <br />SUBCONTRACTOR PHONE m C <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C-57 X C-61 0 D-09 0 Other NUMBER 724778 EXPIRATIONDATE 08/1% <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section - <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: FS—yS15m Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement MPumo Repair ❑ Raise Well Casino <br />WELL CONSTRUCTION I <br />Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ 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 ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seat Depth ft 0 Neat Cement (94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped 0 Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other <br />0 Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe <br />PUMP ikfubmersibleo Turbine ❑ Other HP 1 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 COMPENSATTOW-EA44S , <br />MINI <br />SIGNED <br />X2/4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE CEO I <br />...sem„ W1 <br />rom the road. See insert. <br />NOTE: <br />PUMP SET & STANDING WATER LEVEL <br />w -0 DEPARTMENT USE ONLY <br />G <br />Application Accepted By �- Date (i- t ' % Area ' Employee ID# v <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By H Date WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />to <br />M <br />M <br />D <br />0 <br />0 <br />A <br />m <br />7 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />heck# <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />43��-�? <br />EHD 43.06 <br />8!04108 WELL /PUMP PERMIT <br />