Laserfiche WebLink
WELUPUMP PERMIT <br /> SAN JOAQUIN 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 /> JOB ADDRESS ` G�Jy /�lLs l/ CITYRIP� Jc l Z m <br /> p <br /> CROSS STREET C GJ APN PARCEL SIZE LAND USE APPLICATION# <br /> m <br /> OWNER NAME JL PHONE <br /> OWNER ADDRESS /� ��' CITY/STATE/ZIP <br /> CONTRACTOR PHONE 7 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP J 4.� <br /> SUBCONTRACTOR (_�►'�t/ PHONE Z <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57h <br /> O <br /> 61 D-09 ter NUMBER ^ l <br /> - �'�� EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Prlvat Irrigation/Agricultural Industrial Water Quality Monitoring r Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water ystem Name Contact ame or one um er <br /> TYPE OF WORK ''New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> I<WeW Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method.Mud tary 1 Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth Yao ft Excavation _ in diameter I Open Bottom ><Gravel Pack/Gravel Size in diameter <br /> Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Cj_ in Thickness/Gauge/ASTM Sched 7w— Steel ?{Plastic 1 Stainle St�e1el Other <br /> h <br /> Grout Seal DeptL ft Neat Cement(94 Ib bag/5-10 gal water) XSand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method mped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal 'Dimensions:Width ft Length ft Thick in i Christy Box i 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 /> ,!OAQ'IN COUNTY ORDINANCES, S-A,z LCtlttc A,,n RULES "'d',} REu1Lr'.T:CtiS. i G_80 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- 224HOU DVANCE NOTICE REQUIRED FOUR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED_ ��(/� /�(9►.- TITLE t DATE l ) L� <br /> HLe <br /> f i i i r7 <br /> } a <br /> i <br /> r Y <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request If <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />