WP0039287 - Laserfiche WebLink

Home Browse Search

c-u? = 3'3D WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ,t k IJP CITY/ZIP r^ CROSS STREET-C APN ©0�` 6,r��^ PARCEL SIZE + z" LAND USE APPLICATION# 7�p OWNER NAME PHONE ��`� � y y OWNER ADDRESS CITY/STATE/ZIP 7 CONTRACTOR �/�r) /Q�(Xb`C �/R-i 4� , PHON � zl" 2-r CONTRACTOR ADDRESS r v �`�< / CITY/STATE/ZIP "�'" "69/yp__` _Z;�i SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE -<C-57 I i C-61 D-09 ❑ Other NUMBER . 3jN17 EXPIRATION DATE )-d' 1 �_✓v GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE omestic/Private I Irrigation/Agricultural 1 Industrial I Water Quality Monitoring l i Soil Sampling/Characterization I Public Water System If different from Owner: Water System Name ---------C—ontact Name or Phone um er TYPE OF WORK ^ew Well ;_eplacement Well ❑ Well Alteration/Modification I Other Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings Out-Of-Service Well ❑ Out-Of-Service Well Renewal I Cross-Connection Repair ew Pum 1 Pump Replacement ❑ Pump Repair i i Raise Well Casing WELL CONSTRUCTION Drilling Method,><Mud Rotary I Air Rotary i Auger Cable Tool i Push Point Other Proposed Well Depth ZZ1 ft Excavation in diameter 1 Open Bottom -/-CGravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter� in Thickness/Gauge/ASTM Sched — Steel Plastic i i Stainless Steel i i Other Grout Seal Dept 1' ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement A� e sack mix/7 gal water I I Bentonite(20%solids) ❑ Other Grout Placement Method Pumped I Free Fall i I Other -i Retardant/Accelerator(name) PEDESTAL Installed By XDriller ❑ Pump Contractor Other i Concrete Pedestal I'Dimensions:Width—3L__ft Length ft Thick in Christy Box 1 1 Stove Pipe PUMP P(Submersible I Turbine 1 1 Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOA©UIN COUNTY ORD!NANCES, STATE LAWS, AND RULES AND REGULAT!0NS. I ALSO CERTIFY THAT 1101Y REQUIRED- LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)953-7697 SIGNED •e✓ TITLE ��` DATEAll I e 1l � L r C lJ • L 16 DEPARTMENT USE ONLY HEA�t Application Accepted By Date i L Area u ` Employee ID# L S r Grout Inspection Date_ ❑ SPECIAL Well Permit "uiiip Inspertinn 11 WAIVER Received Soil Boring Inspection By Date Cons rutted Well Depth ft COMMENTS 0 L�_ dJ pw- SZ4,4L ilu I G w PE Sc Received Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service Request # Invoice# Well ID# 5� _+0, s 0j C003q 20 3 14 5- 0 EHD 43-06 WELL/PUMP PERMIT 4/30;12