WP0038549 - Laserfiche WebLink

Home Browse Search

WELUPUMP PERMIT P �� SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 "NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED (�O CITY21P O d wale l e [ S36/ m FB ADDRESS n V r C U/' 2� / D l i O v CROSS STREET �}f� {.V1 - APN 22,9 -22-O-6Z 6 PARCEL SIZE/.Z LAND USE APPLICATION If m T ` f ` y OWNER NAME JLC)"� r1C//��C- Zf jQC%LkC11eje- �J IJ ��{{ PHONE 4oq - �SSy 7/ OWNER ADDRESS Pt r> , R'n' 11&0 0 CITY/STATE/ZIP OeA WO,I F. . 1 s �s-?6 I CONTRACTOR M 6je I ((s r I I I')"oll J�lArPHONE/�.52,7--/ Iq 2-8 c CONTRACTOR ADDRESS lI be l 5 I L� CITY/STATE/ZIP / GI / 5-3✓1 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 I C-61 i I D-09 11 Other NUMBER G(02-.r- ( EXPIRATION DATE -30"/J y GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE U Domestic/Private Xrrigation/Agricultural U Industrial _, Water Quality Monitoring U Soil Sampling/Characterization Cl Public Water System If different from Owner: Water System Name fact Name or Phone Number TYPE OF WORK New Well I1 Replacement Well ❑ Well Alteration/Modification ❑ Other U Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings U Geotechnical #of borings ❑ Out-Of-Service Well LI Out-Of-Service Well Renewal ❑ Cross-Connection Repair I1 New Pump n Pump Replacement ❑ Pump Repair 11 Raise Well Casing WELL CONSTRUCTION Drilling Methodx-Mud Rotary ❑ Air Rotary ❑ Auger Ll Cable Tool U Push Point ❑ Other Proposed Well Depth 500 ft Excavation in diameter ❑ Open Bottom XGravei Pack/Gravel Siz in diameter U Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter in Thickness/Gauge/ASTM Sched d.i.50 Steel ❑ Plastic C Stainless Steel ❑ Other Grout Seal Depth ft C'. Neat Cement(94 Ib bag/5-10 gal water) Sand Cement /101 .s sack mix/7 gal water '.I Bent it (20%solids) �1 Other Ix Grout Placement Method , Limped :_i Free Fall F- Other L' Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other Concrete Pedestal -Dimensions:Width ft Length ft Thick in ❑ Christy Box n Stove Pipe PUMP 1- Submersible I! Turbine I; Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENS ION LAWS. MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209) 9953/-7697 / SIGNED TI LE 1 J/t r DATE —/� -/0 l SAN J A UI C U EP RTMENT U E /ONLY Application Accepted By Daterr Area Employee ID� Grout Inspection By NJ Date (� 2�1� ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By to Constructed Well Depth ft COM ENTS CSU G I'1 co C C J't 03 CeMGnt 01r rwil PE Sc Flce ve hec / 'A-mou-NT Permit/ Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# SGS 35 EHD 43-06 WELL/PUMP PERMIT 4/30/12