Laserfiche WebLink
WELUPUI! P,PERMIT ' <br /> SAN-JOAQU!N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /100 a�& CITY2IP J ICICI m <br /> �, D <br /> J, t 0 <br /> CROSS STREET -�/"(� �/�m�APN PARCEL SIZE LAND USE APPLICATION# /'bf_ m <br /> twn- y. m <br /> OWNER NAME PHONE?/K-J W-- !7!7 7_7 I <br /> OWNER ADDRESS (S /��" CITY/STATE/ZIP '7�/ �j <br /> CONTRACTOR A r /` Crus � ��J�{j /-PHONE 3J 1' 7 7 <br /> CONTRACTOR ADDRESS AO ON 1-7,? CITY/STATE/ZIP C,�/0 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS `CITY/STATE/ZIP <br /> LICENSE �-57 C-61 ❑ D-09 I Other NUMBER 3-2 f C?T EXPIRATION DATE ` <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section _ <br /> INTENDED USE •.<6omestic/Private Irrigation/Agricultural 11 Industrial Water Quality Monitoring 11 Soil Sampling/Characterization <br /> Public Water System_ <br /> If different from Owner: Water System Name Contact Name or Phone um er <br /> TYPE OF WORK 1 1 New Well ,eplacement Well i Well Alteration/Modification I Other <br /> I Monitoring Well(s) #of wells i Soil Boring(s) #of borings I Geotechnical #of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal I Cross-Connection Repair <br /> ew Pump i i Pump Replacement i Pump Repair 1 1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method�Aud^�Rotary ❑ Air Rotary 1 Auger Cable Tool Push Point Other <br /> Proposed Well Depth S J0 It Excavation I) in diameter Open Bottom XGravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth _ ft <br /> Well Casing Diameter-6 in Thickness/Gauge/ASTM Sched i—Op Steel Xlastic 1 Stainl[' Steel Other <br /> Grout Seal Depth_ft i Neat Cement(94 Ib bag/5-10 gal water) x1 and Cement !01 sack mW7 gal water <br /> I Bentonite(20%solids) 1.1 Other <br /> Grout Placement Method i-Wimped I! Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By )N[Driller Pump Contractor Other <br /> Concrete Pedestal ' Dimensions:Width ft Length=ft Thick in Christy Box I Stove Pipe <br /> PUMP Vubmersible Turbine Other HP Pump Set It 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 /> MIN1�4 HOUADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)95f3-/7697/ <br /> SIGNED_ �� TITLE W/+� _ DATE <br /> IT-3 A <br /> I t <br /> r I �CJt <br /> t <br /> Lt <br /> I � <br /> 0 ' <br /> CA <br /> i <br /> LAM O O IG U1 fl( <br /> El E <br /> NT <br /> DEPARTMENT USE O LY <br /> l <br /> Application Accepted B Date xo Area-0147" _ Employee ID# <br /> Grout Inspection By Date �' r ❑ SPECIAL Well Permit <br /> Pump Inspection B Date ❑ WAIVER Received <br /> Soil Boring Ins p ction By Date Constructed Well Dept ft <br /> II ff2 MlllCOM E TS O W . tg <br /> PE SC Receivedec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> �, zo , �.0��70� W p3lvZ�2 <br /> o.5` Ji 3 _02 <br /> EHD 43-06 `lJ � w^ v ' WELL/PUMP PERNAIT <br /> 4/30/12 <br />