Laserfiche WebLink
N I `/;r/// <br /> 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 /> J' q r to <br /> fT .� r C4 �����11 C <br /> CITY/ZIP r��1'- f"�S r 9d 3� m <br /> JOB ADDRESS �_ m <br /> CROSS STREET ti**ye_A APN-Aft , <br /> IR 2349 7 /9 PARCEL <br /> SIIZE�S' LAND USE APPLICATION#!� m <br /> �s7 c <br /> OWNER NAME Ch L ' FiP- 't s' `�_ 1C!r"r✓ /tel WI/7 PHONE <br /> A f , co <br /> OWNER ADDRESS`it o Z � gtalf r CITY/STATE/ZIP V�/// <br /> CONTRACTOR Y LIIGPHONE �ZZ—odo <br /> CONTRACTOR ADDRESS A l ty" CITY/STATE/ZIP ^ yw <br /> q <br /> G <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ^7 <br /> LICENSE XP-57 17 C-61 i 1 D-09 11 Other NUMBER 'L EXPIRATION DATE r7el 1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private E, Irrigation/Agricultural U Industrial ❑ Water Quality Monitoring Cl Soil Sampling/Characterization <br /> 1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone um er <br /> TYPE OF WORK XNew Well Il 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 /> F1 New Pump O Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodXMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other <br /> Proposed Well Depth ,Z2,O ft Excavation � in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched �h ( U Steel �'lastic C Stainless Steel ❑ Other <br /> Grout Seal Depth _ft 1 i Neat Cement(94 Ib bag/5-�o✓ Der) ❑ Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) 11 Other <br /> Grout Placement Method XPumped ❑ Free Fall i Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> n Concrete Pedestal ;^Dimensions:Width It Length ft Thick in D Christy Box ❑ Stove Pipe <br /> PUMP 17 Submersible LI Turbine f' Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE 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 COMPENSATION LAWS, <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)95`3J-76977 <br /> $IGNE L TITLE kJ�" \eH DATER 3 � / <br /> eo <br /> R <br /> van <br /> Y . <br /> j <br /> F IN <br /> T <br /> v I i M I <br /> - _ <br /> -L_- 1 - 1— U-- !-- U �- <br /> D PARTMENT U'S ONLY <br /> Application Accepted Cate 2 AreaWem Employee IDft <br /> Grout Inspection B , Date SPECIAL Well Permit ' 44r" <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> G -If <br /> ac C <br /> PE Sc Received a Amount Per i <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> ff va �� h SZ007&?7Zj 7poo3au�� <br /> �- ? 007 7 7 -- <br /> EHD 43-06 - i �,ae, <br /> 4/30/12 <br />