Laserfiche WebLink
WELUPUMP PERMIT <br /> SAN JOAOU'y 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 ( ` O t 7 c CITY21P / /�Li D <br /> r <br /> CROSS STREET Vim///+C G� APN CJV 7�� UI `PARCEL SIZE LAND USE APPLICATION#] (� <br /> OWNER NAME K f y" PHONE �) r <br /> OWNER ADDRESS /j CITY/STATE/ZIP <br /> CONTRACTOR A( — �� �2 l[.,U r PHONE 3 3 y` <br /> CONTRACTOR ADDRESS v CITY/STATE/ZIP e�t <br /> SUBCONTRACTOR /4 C f l 9 � C�E /y�.� PHONE -L-2-7 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE b�-57 C-61 I I D-09 Other NUMBER 7:7 33 C EXPIRATION DATE "— <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private I Irrigation/Agricultural I I Industrial Water Quality Monitoring I I Soil Sampling/Chara <br /> Public Water System <br /> If different from Owner: Water System Name Contact ame or Phone um <br /> TYPE OF WORK ew Well Replacement Well Well Alteration/Modification Othery <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical # f gri <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair JOA <br /> ew Pum Pum Replacement Pum Repair Raise Well Casing74,p N CNV/RON/NCOU <br /> WELL CONSTRUCTION N <br /> Drilling Method XMud Rotary I Air Rotary Auger 1 1 Cable Tool I Push Point i Other MFNT <br /> Proposed Well Depth4�;V' ft Excavation 1'7- in diameter 1 1 Open Bottom /Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 167 in Thickness/Gauge/ASTM Schede Steel >6astic Stainless Steel I Other <br /> Grout Seal Depth _ ft Neat Cement(94 Ib bag/5 10 gal water) and Cement z sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method�<Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller Pump Contractor Other <br /> Concrete Pedestal (Dimensions:Width It Length It Thick in Christy Box ' Stove Pipe <br /> PUMP `<Submersible Turbine Other HP J 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 HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATIO S. <br /> MINIMU H AD AN NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE ���JA.�fti DATE <br /> N. <br /> DE RTMENT USE ONL ` . � <br /> Application Accepted By Date-oh Area Employee ID <br /> Grout Inspection By Date di2 1 cY 1-1 SPECIAL Well Perms <br /> Pump Inspection By Date 1-1 WAIVER Received _ <br /> 7 <br /> Soil Boring Inspection By Date Constructed Well Depth J ,5 ft <br /> COMMENTS i�a - I4 Z re x(' 5��, -Yn <br /> PE SC Received QUWRW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> )�a�9 z o ry N W P . I � <br /> zy <br /> '/365VEH <br /> Z ����� Z� WELL/PUMP PERMIT <br />