Laserfiche WebLink
l <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN 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 cn <br /> JOB ADDRESS uloj Law CITY/ZIP G <br /> CROSS STREET PN JOIDv ` / PARCEL SIZE LAND USE APPLICATION# m <br /> Cn <br /> "1 <br /> OWNER NAME n <br /> N <br /> PHONE <br /> OWNER ADDRESS fL CITY/STATE/ZIP A� 7 0- j-31 <br /> �-6 <br /> C HONE / W -31 Jdr <br /> CONTRACTOR A qty—.--- <br /> CONTRACTOR ADDRESS ,` CITY/STATE/ZIP <br /> SUBCONTRACTOR A 4 A PHONE <br /> SUBCONTRACTOR ADDRESS r.ITY/STATE/ZIP <br /> LICENSE ' C-57 '1 C-61 i) D-09 n Other NUMBER 110 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization <br /> Cl Public Water System <br /> If different from Owner: Water System Name ontact ame or P one umber <br /> TYPE OF WORK n New Well LI Replacement Well 0 Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 0 Out-Of-Service ell ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> II New Pump Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method L1 Mud Rotary ❑ Air Rotary F', Auger ❑ Cable Tool L] 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 J Steel ❑ Plastic C Stainless Steel 0 Other <br /> Grout Seal Depth It [1 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) 1 Other <br /> Grout Placement Method u Pumped =1 Free Fall f7l Other [I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 7 Pump Contractor ❑ Other <br /> Concrete Pedestal CDimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible[_1 Turbine I; Other HP Pump Set--LQ-C—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 COMPENShjjON LAWS. <br /> NIMUM HO A VANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)9 3-7697 <br /> SIGNED TITLE DATE {t <br /> SAN <br /> IV 1,10 <br /> Eq <br /> a rx <br /> DEPARTMENT SE N L Y <br /> c <br /> Application Accepted By Date 6� Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Ch Amount Permit/ <br /> Codes Inf By Cash Remitted Date Service Request# Invoice# Well ID# <br /> 5 /Sy7S WF00,3090q <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4130/12 <br />