Laserfiche WebLink
WELUPUMP PERMIT ) /g` <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST H ELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> r y <br /> JDA ADDRESS ( ( S / 'A'V Y CITY/ZIP V490 6 -'r m <br /> M D <br /> D <br /> �-'d4Gf APN 1 93 -J30-444 �� <br /> CROSS STREET PARCEL SIZE AND USE APPLI�/CATION� m <br /> OWNER NAME �o 4�G • '�'�Y �6�/�L✓��A PHHONA�/egQ/- N <br /> OWNER ADDRESS /Grys I"79�1/IT��Y' CIN/STATE/ZIP <br /> CONTRACTOR ao JI,L1j('✓ �1�� •Ani CA-V- / PHONE Xe y <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE21P <br /> LICENSE, I C-57 � J? <br /> -61 I I D-09 I Other NUMBER_ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE &4Aomestic/Private :Irrigation/Agricultural •t Industrial I Water Quality Monitoring I Soil Sampling/Characterization <br /> I Public Water System <br /> 1f different from Owner Water bystern Name L;DnIaCt Name or Phone NumDer <br /> e <br /> TYPE OF WORK I New Well I I Replacement Well I Well Alteration/Modification I I Other <br /> i I MonitoringWell(s) #of wells I Sol[Boring(s) #of borings i Geotechnical of borings <br /> I Out-Of-Service Well I Out-Of-Service Well Renewal I I Cross-Connection Repair <br /> I New PumPump Replacement I Pump Repair I I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method [I Mud Rotary I I Air Rotary 11 Auger I I Cable Tool I I Push Point ii Other <br /> Propose Well Depth ft Excavation in diameter Cl Open Bottom I..]Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth it <br /> ell C Diameter in Thickness/Gauge/ASTM Sched� )kSteel 11 Plastic f: Stainless Steel f Other <br /> Seal Depth / O It I I Neat Cement(94 111 bagl5-10 gal water) I I Sand Cement sack m1x/7 gal water <br /> I I Bentonite(20%solids) II Other <br /> Grout Placement Method I I Pumped f l Free Fall fl Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller I Pump Contractor I I Other <br /> I Concrete Pedestal f iDimenslons:Width ft Length ft Thick in I Christy Box fl Stove PI pe <br /> PUMP IbSubmemlblel.l Turbine LI Other HP Pump Set =CLft 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 <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR AD 0 REQUIRED FOR INSPECTI'ONNSSA-PLEASE CALL(209)953-7697 �*r <br /> SIGNED ITLE ✓'��1A DATE 6- <br /> 29 2018 <br /> OUMFNTJNTY <br /> 'Nev <br /> DRT ENT U E 0 LX <br /> Application Accepted By Date (Jx Area Employee ID# <br /> AONW--2 <br /> Grout Inspection By Date r ❑ SPECIAL Well Permit <br /> Pump Inspection By J Date Vit <br /> ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PESC Received Che Amount Permit/Co s Inffo�� By <br /> Remitted Date Service Request# Invoice It Well ID# <br /> 7 <br /> EHO 43-06 WELL/PUMP PERMIT <br /> 4130112 <br />