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 /> a���,5 7 ����jam.✓ 2� <br /> JOB ADDRESS CITY/ZIP C ��A �51zo D <br /> 0 <br /> CROSS STREET L� A� APN 6 /-11,1 0( I PARCEL SIZE I ?) LAND USE APPLICATION# <br /> OWNER NAME f1/V n ^�/,�/ �j 2� -7f(I- 9V3 7 y <br /> �j C�' !�'C ( ��/T��• '/` �'/ P/H�O,yN�E/��//� ^ <br /> OWNER ADDRESS L�(1�� / ��) ��{_5/ _1�/ �G/ CITY/STATE/ZIP �C T/�`�//�/Q/J i ,14 <br /> CONTRACTOR x5l�' y}� /�LL1�L�//�L% �//f�i ,! PHONfir,C�"/ �T� �2J/?`rj7C <br /> CONTRACTOR ADDRESS r/�L>rY/Y'T/') /�/� CITY/STATE/ZIP��__ykeee7 S e <br /> �I � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP Z <br /> LICENSE NC-57 C-61 i D-09 Other ZZ // NUMBER /" EXPIRATION DATE'g-31 �B <br /> GEOGRAPHICAL INFORMATION: Coordinates X i�/f��J'�f4 Y'�1Z��1Z��1� Township Range Section <br /> INTENDED USE i Domestic/Private iX Irrigation/Agricultural Industrial I Water Quality Monitoring i Soil Sampling/Characterization <br /> Public Water System rNA <br /> If different from Owner: Water System Name -------Contact Name or Phone Number �p <br /> TYPE OF WORK jd New Well I Replacement Well Well Alteration/Modification 1 1 Other IF-I �/�\►'� <br /> I Monitoring Well(s) #of wells i Soil Boring(s) #of borings Geotechnical____ #11of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal i Cross-Connection Repair ►UrV 18 2018 <br /> New Pump Pump Replacement 1 Pump Repair Raise Well Casing SAN <br /> WELL CONSTRUCTION ENVIRONMEN NTY <br /> Drilling Method A'Mud Rotary i Air Rotary i Auger i i Cable Tool Push Point i Other HEALTH DEPARTME41;: <br /> i <br /> Proposed Well Depth �b ft Excavation /Z /y in diameter Open Bottom ;( Gravel Pack/Gravel Size 31/4, in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_�e in Thickness/Gauge/ASTM Sched J&je 2 r Steel ^ Plastic Stainless Steel Other <br /> Grout Seal Depth %Qz ft Neat Cement(94 Ib bag/5-10 gal water) X Sand Cement _le,,'•j sack miyJ7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By V Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width±-:L ft Length ft Thick (v in Christy Box Stove Pipe <br /> PUMP 'Submersible Turbine Other Z 2_1^ Z- HP Pump Set !&O ft Standing Water Level <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 COMPEN QN LAWS. <br /> MINIMUW9WI10UR AD E NOTICE ICE REQUIRED FOR SPECTI NS- PLEASE CALL(209) 53-7697 <br /> SIGNEDTITLE DATE <br /> i <br /> I <br /> EP R T M E N T USE NLY <br /> Application Accepted By Date - Area Employee ID# <br /> Grout Inspection By Date �1 tiff L Well Permit <br /> Pump Inspection By job Date �U j ?)�, I] WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check# Amount Date Permit/ Invoice# Well ID# <br /> Codes �rftBy Remitted Service Request# <br /> ko 0 &/ <br /> 6-1`84 U/ dO I )L, <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />