Laserfiche WebLink
u <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PER IT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 25001 KASSON RD CITY/ZIP TRACY, 95304 In <br /> LI <br /> 1 r.Iv C <br /> CROSS STREET H V V' i3 APN 0-;-O PARCEL SIZE LAND USE APPLICATION# <br /> MM <br /> OWNER NAME SKYDIVE CALIFORNIA LLC( P 00 e 3273742 <br /> OWNER ADDRESS 25001 KASSON RD/3`091 U� CITY/STATE/ZIP T MAN `'Y LIQ <br /> CONTRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W. MAIN STREET CITY/STATE/ZIP RIPON CA, 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural i Industrial i Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner'. a er System Name contact Name or Fhone NUMber <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump X Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b 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 Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine Other HP Pump Set 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 /> JO OUNTY OR NANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> RRENT A D ACTIV WITH THE LIFORNIA C NTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> W ERS C MPENS IN S. <br /> IN MUM 2 H UR N OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7'7697 <br /> SIGNED TITLE ?I btyc DATE -7- C,�� <br /> N <br /> E <br /> S <br /> pAYME <br /> RE�EIV <br /> SX, JOAQUV C U <br /> RpEPAWE <br /> RT�tE E P R T M E N T S E N L Y <br /> ill, 4A <br /> Application Accepted By Date Area,< Employee ID# W"'�'J <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By U Date _ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che I Amount Date Permit/ Invoice# WeIIID# <br /> Codes Info B as Remitted Service Re uest# <br /> Sod& a 7 �J DD3bl <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/72 <br />