Laserfiche WebLink
J WELUPUMP PERMIT <br /> •SAN J0,10UIN 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 2. O N <br /> �/G� MD—� CITY21P Axm 'o"� �SZ m <br /> CROSS STREET l&L <br /> APN PARCEL SIZE BLAND USE APPLICATION# m <br /> OWNER NAME Cal <br /> ,Q� m0 l PHONE <br /> Oil <br /> OWNER ADDRESS /s 1''✓ ' CITY/STATE/ZIP �f �/ <br /> CONTRACTOR � � e PHO E.�� / -C ir �- <br /> CONTRACTOR ADDRESS w 7Y <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE l —C-57 C-61 D-09 Other NUMBER)77 k?Y EXPIRATION DATE C-17 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ,<Ibomestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: ater ystem Name ontact Name or Phone Number <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 nn D <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair 31 2016 <br /> ew Pump Pump Replacement Pump Repair Raise Well Casing SAN <br /> WELL CONSTRUCTION IV <br /> H� Ntt1[a0 CpUN <br /> 71,� <br /> Drilling MethodMud Rotary Air Rotary Auger Cable Tool Push Point Other ALT H f„- �Z�Aj_ <br /> Proposed Well Depth ci ft Excavation t'l� in diameter Open Bottom >cGravel Pack/Gravel Size in diametBr <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched7 ';0 Steel Mastic Stain] ss Steel Other <br /> Grout Seal Depth /,:)<7 ft Neat Cement(94 Ib bag/5-10 gal water) ><Sand Cement / sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method *[Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By reDriller 1 Pump Contractor i Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> oe <br /> PUMP6ubmersible Turbine Other HPl�_ 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 /> MINIM 2 HR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED /1� / TITLE 4211./� DATE Z?— <br /> l � <br /> r <br /> DE ARTMENT SE ONLY <br /> Application Accepted B to30 Area Employee ID# <br /> Grout Inspection [late ❑ SPECIAL Well Permit <br /> Pump Inspection y lzra Date ZOO& CI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS OeP I-r <br /> PE SC Received Check# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 0 Slzoo-75te5 _f1 <br /> z.l � 3t I cc ,� 5co5 136 <br /> I <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />