Laserfiche WebLink
fJ <br /> WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3R°FL-STOCKTON CA 45202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS alffli— CITYIZI � <br /> CROSS STREET S4 AjPN t03-2-80-- 03 PARCEL SIZE`4-4S LAND USE APPLICATION# <br /> OWNER NAME PHONEZQgq(A _. alu <br /> OWNER ADDRESS CITY/STA <br /> I <br /> CONTRACTOR A7LX-A <br /> PHONE ZL2?7,�� <br /> I <br /> CONTRACTOR ADDRESS212o <br /> ��[, ���i �t -� �y <br /> � I CITYISTATE/ZIP <br /> SUBCONTRACTOR4C!N 44 )e7��_ <br /> PHONE <br /> ^-) <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> X-57 ❑C-61 13D-04 ❑Other NUMBE4bffl EXPIRATION DATE <br /> GEOGRAPHICAL W <br /> ATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different fromowner: Water System Name Contact Name or Phone Numkr <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Vyl ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump E,,PumpReplacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter {� <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Q <br /> Grout Seal Depth ft ❑Neat Cement(94!b bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(201/o solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP "E�—Pump Set 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 fh <br /> i WORKE COMPENSATION LAWS. <br /> f; IMINWM Lffi HOUR ADVANCE NOTICFREQUIRIVD FOR INSPECTIONS <br /> SIGNED TITLE I)ATF &2907 <br /> LK <br /> I\! F <br /> LL Jf <br /> SAN JOADUN GOL NT e <br /> j1541EN R N E qTA L <br /> I <br /> k <br /> DEPARTMENT V SE O N L Y <br /> Application Accepted By Date Area Employee ID# —73-7 IF <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection B Date ❑ WAIVER Received <br /> s Constructed Well Depth ft <br /> COMMENTS ? �< d � yj ✓ �ral. ey " <br /> Cs -•�S?.9�G'>i C,l��" �/ /�6�1���/����CG�/j"d'.+G{S7d��C!(r�s <br /> I PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> SK()o <br /> i <br /> EHD 43-02.006 WELL PUMP PERMIT <br /> 1l27n00s <br />