Laserfiche WebLink
�z l <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN CJUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)466-3420 <br /> NON-Rd UNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 'W` /-y CITY/ZIP /j�'iYJL/� D <br /> 0 <br /> CROSS STREET AP ?-(P5 <br /> J C(C C 0(D PARCEL SIZE _LAND USE APPLICATION# m <br /> m <br /> OWNER NAME Vr�Y1Y11� �� PC�t�1e\C\ LJQ�tiQS �7 `P7HONE (Toc 3C)` 1521 y <br /> OWNERADDRESS 3(D2OC�Z SClYtV1 C h"f-�StACkVA V-aCA CITY/STATE/ZIP TC-C-:C'vj . C - <br /> CONTRACTOR ^���1 1 '�U �. r1Yt('\�YSG►'1 PHONE <br /> CONTRACTOR ADDRESS �GiC Z 1( <br /> � 1C�USt'- ACI` W(\l j CITY/STATE/ZIP L-ocyl C <br /> ;-1 `152 16 <br /> SUBCONTRACTOR tJ I PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP q <br /> LICENSE ✓C-57 C-61 D-09 Other NUMBER L CCC C C q EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates . (otV] Y-QZ1_ )' LL-M 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 Contact Name or Flhone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells V Soil Boring(s) l #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary \,/Auger Cable Tool Push Point Other <br /> Proposed Well Depth LSU, ft Excavation (C 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 Plastic Stainless Steel Other <br /> Grout Seal Depth ft >fIQeat Cement(94 lb bag/5-10 gal water) /` Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) %✓ <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 /> Mlj 24 H . �ANCE NOTICE REQUIRED FOR IN_S/PECT/IONS - PLEASE CALL (209) 953-7697 <br /> SIGNED I �� TITLE�el�7MIC4% �edt �QMQ(� DATE .3✓ <br /> Qtj A, <br /> N � <br /> R <br /> EP RTMENT USE QNLY <br /> Application Accepted By Date l� Area Employee ID#Ax� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Xheckffl> Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> 2 (� Ib WP()U3Ea(�5 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />