Laserfiche WebLink
141 = !"'r 5 Lu.j to-}t- (b o i;wn 1. <br /> "A/w WELUPUMP PERMIT ' <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> 11,11IG !-i<FUNDABLE PERMIT CALL(209)953-7697 FOR INSPECT IONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> t — t ----- 'n cn <br /> JOB ADDRESS 7 �J'�r2-A A„ I\ CITY/ZIP 4G/t pm �(0, O <br /> CROSS STREET ` LL / /�/ AP/N 0 PARCEL SIZE J LAND USE APPLICATION# � <br /> OWNER NAME`4` TSO Z/1` , /r P PHONE S <br /> bolle-t l y,e,- <br /> OWNER ADDRESS CCITY/STATE/ZIPCONTRACTOR �/ � n64'-1 /A L PHOONNEj33 <br /> CONTRACTOR ADDRESS Z ` CITY/STATE/ZIP114_ / A,Afl <br /> 100, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �,S-57 ' C-61 ri D-09 Ll Other NUMBER 3 �71?f <br /> EXPIRATION DATE--6--/7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE '<Domestic/Private Irrigation/Agricultural U Industrial Water Quality Monitoring o Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Jew Well Replacement Well Well Alteration/Modification Other <br /> /❑ Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Sy❑✓,�O�''ut-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ,mvew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,,>I5 lud Rotary U Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth'3,;o ft Excavation 11- in diameter Open Bottom gavel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-C— in Thickness/Gauge/ASTM Schad 7-ao ISteel %Plastic 1 Stainless Steel Other <br /> Grout Seal Depth l ft Neat Cement(94 lb bag/5-10 gal water) -44,Sand Cement A20 sack mix/7 gal water <br /> Bentonite(20%solids) I Other <br /> Grout Placement Method >ePumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By driller Pump Contract r I Other <br /> Concrete Pedestal Dimensions:Width it Length Sp it Thick =in Christy Box 1 Stove Pipe-- <br /> au_MP <br /> ipePUMP N4Submersible ' Turbine Other HP�— Pump Set ft Standing Water Level ft <br /> 1 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 ;S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI�HO(JR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953-769/7 <br /> SIGNED J !✓ TITLE w DATE <br /> U <br /> 0. <br /> E <br /> kry JC?. to I <br /> M A <br /> N <br /> I I 1 3111 1" 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> DE ARTMENT USE N L Y <br /> Application Accepted e Date Area Employee ID#�- <br /> Grout Inspection y Date ❑ PECIAL Well Permit <br /> Pump Inspection By J Date 0 ❑ WAIVER Received <br /> Soil Borin nspection BIL_ Date Constructed Well Depth ft <br /> NTS <br /> COMME �( ti Qc 0`�Y>� f <br /> w C ( D c <br /> PE SC Received heck#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> VWp003tos►tv <br /> lu ZsIN CM007(pog3 w pogq2 q S <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />