Laserfiche WebLink
WELUPUMP PERMIT <br /> 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 /> JOB ADDRESS 7Z L G t ly.!P-t 15ze'/ -- CITY/ZIP I�-���� G 95 D <br /> CROSS STREET �✓t �� APN�� `��L' 7G' PARCEL SIZE h,LAND USE APPLICATION# m <br /> �1 ���� <br /> OWNER NAME y � q v PHONE <br /> /�� , <br /> OWNER ADDRE S� ✓ O C CITY/STATE/ZIP S7� 4 25Ze7 <br /> CONTRACTOR ` PHONE /✓�� /� <br /> t <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR �1'[�i/S. PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE Y,-C-57 )IOC-61 i 1 D-09 11 Other NUMBER_1_298'-16 EXPIRATION DATE / J <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE >VbomestiC/Private ["1 Irrigation/Agricultural ❑ Industrial [-I Water Quality Monitoring U Soil Sampling/Characterization <br /> [1 Public Water System <br /> If different from Owner: Water System Name acl Name or Phone Number <br /> TYPE OF WORK �( lew Well [1 Replacement Well ❑ Well Alteration/Modification F Other <br /> /❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal CJ Cross-Connection Repair <br /> ew Pum [' Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodJ)rtAud Rotary [-I Air Rotary l Auger ❑ Cable Tool U Push Point ❑ Other <br /> Proposed Well Depth �ZeZ? _ft Excavation - /7— in diameter '-� Open Bottom ravel Pack/Gravel Size in diameter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter� � <br /> in hickness/Gauge/ASTM Sched A20f) 'j Steel"I Al0 ❑ <br /> lastic Stainless Steel D Other <br /> Grout Seal Depth ft I V'#, Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack MW7 gal water <br /> I Bentonite(20%solids) '.1 Other <br /> Grout Placement Method Vpumped i=1 Free Fall F. Other [' Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller Pump Contractor D Other <br /> Concrete Pedestal.1-1 Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible[I Turbine I! 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 COMPENWJION LAWS, <br /> MIM VANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)95),769 <br /> SIGNED TITLE �G��6 � DATE <br /> 19 <br /> q <br /> T O C <br /> EP RTMENT U E NLY <br /> Application Accepted By Date Area q-lq <br /> Employee ID# <br /> Grout Inspection By litzp L4ft4*LV�4A'QMI VIC Date 7 q1 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received41hecl&0 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B s Remitted Service Request# <br /> /5 76 §?- M3S"-3 <br /> E D 43-Ofi WELL/PUMP PERMIT <br /> 4/30/12 <br />