Laserfiche WebLink
• WELUPUMP PERMIT <br /> SAN JOAQUIN CbUNTY 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 /> N <br /> 503 t - U m <br /> JOB ADDRESS CITY/ZIP <br /> D <br /> -r N�253-1 <br /> CROSS STREET / �`- AP ARCEL SIZE LAND E�AP�P�LI+CATION# m <br /> OWNER NAME �f PHONE, <br /> OWNER ADDRESS CITY/STATE/ZIP C� <br /> CONTRACTOR /I//` <br /> CONTRACTOR ADDRES / // CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / If <br /> LICENSE 57 r C-61 i) D-09 rl Other NUMBER EXPIRATION DAT <br /> /jq <br /> GEOGRAPHICAL RMA .r teS X Y Township Range Section <br /> INTENDED U Domestic/Private icultural r] Industrial O Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> e <br /> If different from Owner: ater System Name Contact Name or Phone Number <br /> TYPE OF WORK ''New Well I l Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) If of wells ❑ Soil Boring(s) If of borings r_ Geotechnical n of borings <br /> 0 Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> P New Pump - Pump Replacement U Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method . Mud Rotary 0 Air lyAuger ❑ Cable Tool U Push Point [I Other <br /> Proposed Well Depth Exc tion in diameter I Open Bottom "ravel Pack/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter—tl- in <br /> T�ji k Gauge/ASTM Scheclop ,e f I_] Steel fg(Plastic C Stainless Steel ❑ Other <br /> Grout Seal Depth�W=�—i , �: eat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%soli <br /> ds Other <br /> Grout Placement Method Pumped ❑ ree Fall Other [' Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 7 Pump Contractor Ll/Other <br /> Concrete Pedestal -Dimensions:Width it Length ft Thick in ❑ Christy Box F Stove Pipe <br /> PUMP r- SubmersibleU Turbine r; Other HP 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 <br /> WORKERS COMPENSATION LAWS. <br /> MI 24 HOUi ANCE NOTICE REQUIRED FOR LVSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ` TITLE /� DATE <br /> 141 <br /> /RT <br /> i .P Q4 <br /> � Y <br /> 8 <br /> O U TY <br /> a ui <br /> L E <br /> E <br /> ZEPRTMENT URENLY <br /> Application Accepted By DateZArea Employee ID# <br /> Grout Inspection By r� ( Date 0 SPECIAL Well Permit <br /> Pump Inspection By _ Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> OMMENTS O <br /> I - <br /> PE Sc Received heck Amount 3Permit/' Codes Info B s Remitted Date Service Request# Invoice# Well ID# <br />` WPc57?0.=�_ 3039 <br /> 4EHD <br /> 130/12 43'06� I ,-7 //� / �� �D7 ��� WELL/PUMP PERMIT <br />