Laserfiche WebLink
�- WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 9 A/ 7 <br /> j � ,` <br /> JOB ADDRESS <br /> [ r t to Q� CITY/ZIP D <br /> C �//3 v <br /> CROSS STREET� _ APN I O ` /D J PARCEL SIZE 1 L//,/1 LAND USE APPLICATION# m <br /> 39 _510 <br /> OWNER NAME ,PHONE /1 <br /> OWNER ADDRESS P 0 ea IL p,�t �pe CITY/STATE/ZIP�/�L '/�r�j p <br /> CONTRACTOR • ,�cic� rrt l L�� PHONEY'S` [y0 <br /> CONTRACTOR ADDRESS C C I �d L6k,­Q i4 CITY/STATE/ZIP 1'G�-r2,l4 74 ` <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE f i -57 ] C-61 i 1 D-09 [I Other NUMBER lD!°6 (O ZEXPIRATION DATE ZD� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Komestic/Private C- Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization <br /> I l Public Water System <br /> If different from Owner: Water System Name ontact ame or Phone Number <br /> TYPE OF WORK )(New Well I1 Replacement Well 0 Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical n of borings <br /> 0 Out-Of-Service Well U Out-Of-Service Well Renewal [I Cross-Connection Repair <br /> ❑ New Pump U Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method KMud Rotary ❑ Air Rotary ❑ Auger 0 Cable Tool U Push Point ❑ Other <br /> Proposed Well Depth_SOQ ft Excavation 11a _ in diameter ❑ Open Bottom o Gravel Pack/Gravel Size in diameter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_k in Thickness/Gauge/ASTM Sched j 12.0n 'i Steel I ?lastic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth 1-" ft r] Neat Cement(94 Ib bag/5-10 gal water) ,❑`Sand Cement sack mix/7 gal water <br /> `_i Bentonite(20%solids) �1 Other <br /> Grout Placement Method - Pumped _ Free Fall I^ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By [],Driller Pump Contractor ❑ Other <br /> ''. Concrete Pedestal -:Dime sions:Width It Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP F! Submersibleu Turbine f; 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 COMPENSAIION LAWS, <br /> MINIMUM'�InHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIG ED ,►`" TITLE '(00—r DATE <br /> 8 <br /> 7-7 <br /> IA i ity I I L I III I - <br /> L <br /> I= DA RTM ENT USE 0 LY <br /> Application Accepted By Date fArea--(ki qq Employee ID# <br /> Grout Inspection By _ L Date ❑ SPECIAL Well Permit <br /> Pump Inspection By 1�1 i�(la ❑ WAIVER Received <br /> Soil BoringI pection By Date Constructed Well Depth ft <br /> COMMENTS <-1--R_a <br /> PE Sc Receivedk#/ChecAmount Permit/ <br /> Codes Info B as Remitted Date Ser a Request# Invoice# Well ID# <br /> 3s�s� 170 <br /> Us <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />