Laserfiche WebLink
s a <br />E. <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE' <br />DEP R T M ENT U E <br />CALL 209 953-7697 FOR INSPECTIONS <br />1 YEAR FROM DATE ISSUED <br />^PERM'I�T/ <br />JOB ADDRESS : VI yy <br />�y <br />�EAW Csr <br />C—d- <br />�JEXPIRES <br />CITYIZIP.EC-QXIG/I <br />� xmp "1S7i k <br />, ^ \�^ <br />CROSS STREET ►" ank\ 1(' <br />COMMENTS <br />APN �q'1�1nn3�I <br />PARCEL SIZE 0-:� <br />LAND USE APPLICATION # <br />OWNER NAME U/xaD'F3�fPC��` <br />'Cir �.0 <br />PHONE <br />OWNER ADDRESS O F�" <br />j -c-7 <br />61 <br />CITY/STATE/ZIP <br />n <br />6yW R p to <br />, ` <br />CONTRACTOR �Vi�1/k 0 'email <br />flc )C��/n <br />n C t n <br />t�IS/J�6cL (1Tc_ <br />r 2� <br />PHIONE Z/�O-1� V/� J� C <br />CONTRACTOR ADDRESS v1��2 1 ��US{ <br />Y�l(A <br />I IIS InJI <br />CITY/STATE/ZIP L <br />Q l.�t. LSA 0kS7-WO <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE \%C-57 C-61 <br />D-09 <br />Other <br />NUMBER (0 cC�IOC�-/ <br />EXPIRATION DATE S 3 \ <br />GEOGRAPHICAL INFORMATION: Coordinates 7>7'Fc(t0'5 Y -- u—t' ,cps 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: Water System Name (;ontact 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 2- <br />OUt-Of-Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New F'UmD f'UmD KeDlacement rum <br />Raise even %las! <br /># of borings <br />Drilling Method Mud Rotary Air Rotary VAuger Cable Tool Push Point Other <br />Proposed Well Depth 2z, ft Excavation (,o_ in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thicknes /Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft eat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP 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 FOR INSPECTIONS - PLEASE CALL (209)) 953-7697 <br />SIGNED //J fi TITLE �'' DATE <br />;n <br />Area Employee ID#04X� <br />SPE IAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE SC <br />Codes Info <br />DEP R T M ENT U E <br />Application Accepted By 4mONLY <br />Date <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date <br />�r <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />;n <br />Area Employee ID#04X� <br />SPE IAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE SC <br />Codes Info <br />Received <br />B <br />Check#/ <br />Amount <br />emitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />Z� <br />22��1 <br />EHD 43-06 WELL/PUMP PERMIT <br />4/30/12 <br />