WP0038937 - Laserfiche WebLink

Home Browse Search

WELUPUMP PERMIT SAN JOAQ'e4.V COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 fl6B EAST HAZELTON AVENUE-STOCKT6CQ 9521 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR CTIONS EXPIRES 1 YEAR;Ilk, E I SUED JOB ADDRESS r e Q CITY/ZIP 66Xy ( CU m D L/ 0 CROSS STREET 7b wli �QP`N PARCEL SIZE LAND USE APPLICATION# OWNER NAMEp� l _ _ PHONE ' OWNER ADDRESS r r k L) r l CITY/STATE/ZIP ✓ v� `^� (7�41/ 2— CONTRACTOR 1 C �" PHgNE(, C //F'�, CONTRACTOR ADDRESS U CITY/STATE/ZIPS C\ SUBCONTRACTOR _ PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP t LICENSE C-57 C-61 D-09 Other NUMBER -7 19n• v EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE /'<,Domestic/Private Irrigation/Agricultural I Industrial I Water Quality Monitoring Soil Sampling/Characteriz Public WaterSystem If different from Owner: Water System Name ontact Name or Phone Number pR, pM - w TYPE OF WORK a New Well Replacement Well 11 Well Alteration/Modification -1 Other i r 71 Monitoring Well(s) #of wells [I Soil Boring(s) _ It of borings ❑ Geotechnical S f t fipgs 11 Out-Of-Service Well � Out-Of-Service Well Renewal 11 Cross-Connection Repair IQU/ �dl$ New Pum Pum Replacement i Pum Repair 11 Raise Well Casin ALT O /C WELL CONSTRUCTION p9�TTi�� Drilling Method Mud Rotary Air Rotary Auger I Cable Tool [IPush Point Other llFMz- Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter 7 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic Stainless Steel Other Grout Seal Depth ft L Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite(20%solids) G Other Grout Placement Method ❑ Pumped ❑ Free Fall [I Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By `.I Driller C Pump Contractor Other Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe PUMP Submersible! Turbine i Other HP < Pump Set__j Er ft Standing Water Level % ft 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE I,AWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALtFO IIIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE ITH ALL WORKERS CgjMP TION LAWS./ NIMU 24 H U ADV E NOT E REQUIRED F R SPECTIONS - PLEASE CALL(209) 953 697 SIGNED _ TITLE ✓ DATE P A T M ENT U E O L Y Application Accepted By DateArea Employee ID#� Grout Inspection By Date I PECIAL Well Permit Pump Inspection By �IUvQ� Q� Date \ �7r WAIVER Received Soil Boring Inspection By Date _ Constructed Well Depth ft COMMENTS — PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Remitted Service Request# EHD 43-06 WELL/PUMP PERMIT 4/30/12