Laserfiche WebLink
WELUPU IP PERMIT <br /> SA. JOAQJIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTION�^Sp�'�' EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1__Ir' on CITY/ZIP i ✓' W�� D <br /> CROSS STREET �s L� ...�"' A� D d LP LAND USE APPLICATION# M <br /> `�'`� r- -/30 ARCEL SIZE { J �T <br /> , y. L^�/� L F-,f� � V ! � <br /> OWNER NAME PHONE (l a <br /> OWNER ADDRESS C /! CITY/STATE/ZIP <br /> CONTRACTOR �ss PHONE <br /> CONTRACTOR ADDRE/(ill <br /> S CITY/STATE/ZIP ✓�`�� G <br /> SUBCONTRACTOR 4r+ IA•kez �r/r17'r PHONE 3 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICeNS6 >410•57 C-61 0-09 Other _ NumaEAa _ EXPIIIATIONbATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE y<Domestic/Private - Irrigation/Agricultural . Industrial F Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System <br /> If dnt from A yebm Hm& - eQaot <br /> oma Rr Ane..um @f' <br /> Typj OF WgftK,y-,-,New Well Replacement Wall ❑ Well Alteratlan/Modlfloatlon u Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borinpe a Geotechnical n of boringe <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ''New Pum - Pump Replacement 11 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodi-�Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool - Push Point r! Other <br /> Proposed Well Dept[;S SCS ft Excavation 12` in diameter ❑ Open Bottom ,<Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter� in Thickness/Gauge/ASTM Sched7 C ❑ Steel Plastic ❑ Stainl Stepp ❑ Other <br /> Grout Seal Depth�ft ❑ Neat Cement(94 lb bag/5-10 gal water) and Cement 0% J sack mix/7 gal water <br /> ❑ Bentonite(20%solids) FOther <br /> Grout Placement Metho Pumped I Free Fall i Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By rifler mp Contraor•c Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in i i Christy Box i Stove Pipe <br /> PUMP Submersible i Turbine IOther 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 /> 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 /> MINI"M 21 HOAR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209))953-7697 <br /> SIGNED ���' TITLES mk. _J" _ DATE <br /> Yj <br /> r � - <br /> �7 <br /> - E LT H DEFAF T <br /> DEPARTMENT USE ONLY ��Za <br /> Application Accepted B Date Area Employee ID# <br /> Grout Inspec Date ❑ SPECIAL Well Permit <br /> Pump Inspectio Date WAIVER Received <br /> Soil Boring Inspection By !�' Date Constructed Well Depth ft <br /> COMMENTSOld (A* c 'D <br /> PE Sc Received eco Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> 43166 � O X8 341 J l8 , / �� 9/ roo': N <br /> Vll Pvooyl33 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />