Laserfiche WebLink
WELL/PUMP PERMIT <br /> 1' 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 <br /> moi'// _y <br /> JOB ADDRESS L3Z�bb Lvv33 CITY/ZIP —7&qdZL T;1A <br /> CROSS STREET _ "J l K APN �- `�(/ PARCEL SIZE LAND USE APPLICATION#�yc� <br /> OWNER NAME /(/�22k. f�v�twtaii -rr�— PHONE '53 -41Z w <br /> OWNER ADDRESS3< < o a�4 A \ CITY/STATE/ZIP <br /> ✓�/y <br /> CONTRACTOR PHONE <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS 6 <br /> CITYISTATE/ZIP C 0irrr , a.Y 1 •�I�ZC <br /> SUBCONTRACTOR PHONE T� <br /> SUBCONTRACTOR S CITYYISTATE/ZIP <br /> LICENSE I C-57 I I C-61 I D-09 I Other NUMBER Q5% ExPIRATION DATE <br /> GEGGRAP L INFORMATION: Coordinate Y Township_ Range Section <br /> INTENDED USE I Domestic/Private i 'gation/Agricultural i Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water.5y%brn Name on ac ame or one um r <br /> TYPE OF WORK IAewWell i Replacement Well I Well Alteration/Modification i Other <br /> F Monitoring Well(s) #of wells C Soil Boring(s) #of borings -Geotechnical k of borings <br /> I Out-Of-Service Well I Out-Of-Service Well Renewal I Cross-Connection Repair <br /> ew Pump I Pump Replacement I Pump Repair I Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Ro ry I Air Rotary I Auger I Ciible Tool I Push Point i Other ' Z Y), <br /> Proposed Well Depth 660 xcavatiiRn 2&in diameter I Open Bottom I III Pack/Gravel Size III diameter <br /> C Conductor Casing -W;rrieter / Conductor Casing Depth / ft <br /> Well Casing Diameter in Thickness/Gt a/ASTM Schad t 750 I eel I Plastic Stainless Steel i Other <br /> Grout Sea] Depth ft I eaCement(941b bao-10 gal water) I Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) II Other <br /> Grout Placement Method>C Pumped I Free FV I Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ODriller ump Contrfor C Other <br /> Concrete Pedestal I Dimensions:Width�ft Length ft Thick n Christy Box I Stove Pipe <br /> PUMPubmersiblel urbine I I Other HP L Pump Set ( K Standing Water Level ft <br /> I HEREBY R THAT I H E P AIRED HIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN O ORDINAN ST E LAW , AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT ACTIVE WITH E LIFOR EWCONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKER PENSATIO S. <br /> O OTICE REQUIRED FORMONS ONS-PLEASE CALL(209)953#6 <br /> j53 69 <br /> SIGNE TITLE (/C/'✓ DATE V <br /> T <br /> D <br /> 014 <br /> OUNTY <br /> TAL <br /> f N L TMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Z^ Date Area Employee ID# <br /> Grout Inspection By ser Date SPECIAL Well Permit <br /> Pump Inspection By MAZ. Date = WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well De th ft <br /> COM EN S1. `L`• G1 <br /> G <br /> PE SC Received eck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> EHO <br /> 00.7 3 <br /> 430 43-06 w, ( ( W,fj �-� - WELL/PUMP PERMIT <br /> 4/30/12 Y <br />