Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTi•i DEPT 9868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NoN-RE=FUNDABLE PERMF. CALL. 209 953-7697 FOR INSPECTIONS EXPIRES 11 YEAR FROM DATE ISSUED <br /> JOS ADDRESS _ - • (/ Gi l i/ZIP a_l > <br /> CROSS STREET it-CA 'I;,`1 ARCEL SIZE t•SO LAND USE tA,PPLICATION#c m <br /> OWNER NAME \14 QAC(yW PHONE(��F�✓�' J„Q�8 N <br /> OWNERADDRESS h V• � �2�n1 CITY/STATE/Zip►►(� '�(//d1 CSI 6 <br /> M 9 � 6 �+ <br /> CONTRACTOR /•\AS Ll l\f �t\,ZV�1�� PHONE :522--tq IS <br /> U9 <br /> C C <br /> CONTRACTOR ADDRESS 1 A 1 Iae� Rd CITY/STATEIZIP /'l/�/�OGJ�5+��_�9J J <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE )(C-57 ❑ C-6.1 ❑ D-09 ❑ Other NUMBER 2 EXPIRATION DATE V <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from OwnerWater System Name Contact Name or Phone Number <br /> TYPE OF 11NORK XNew Weil ❑ Replacement Well 0 Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) 9 of borings 0 Geotechnical of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 0 New PUMP ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> ,WELL CONSTRUCTION <br /> Oriiiin 3 i.7ethod Mud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> e1 <br /> Proposed Well Depth 340 ft Excavation 7_ in diameter ❑ Open Bottom )(Gravel PacldGravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter� in Thickness/Gauge/ASTM Sched 260 ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth�ft ❑ Neat Cement(94/b bag/540 ga/water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method umped Cl 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 ❑ Sto Pope r�`o <br /> PUMP ❑ Submersible❑ Turbine 0 Other HP Pump Set ft `standing Water Lev 18 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDAN -N (1 <br /> JOAQUIN COUNT`! ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY RE= <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT.1 AM IN COMPLIAN <br /> WORKERS COMPENSATION LAWS. T/y NT <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED � ^ TITLE f DATE <br /> — —A9 At, <br /> —T <br /> Alt <br /> 'D <br /> DE ARTMENT LkSE QNLY ,,��//,,A/y, <br /> Application Accepted By'91 Date " Area Employee ID#aAi7-� <br /> Grout Inspection By ) Date SPECIAL Well Pert- it <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE Sc ReceivedecI%,# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Re uest# <br /> 3S873 J-� I.2b-1N WP0�3� '15 <br /> 3 5 'b-21-1t 03 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />