Laserfiche WebLink
A ~ <br /> 'XELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '3O4 E WEBER AVE 3'n FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` +! `f { CITYIZIP . LLCM' ! 211 "���� 9 <br /> C007.5— <br /> q (j "t� <br /> CROSS STREET APN oa 5-©��— OARCEL SIZE S L LAND USE APPLICATION# C.�O T F <br /> OWNER NAME L PHONE. M! <br /> OWNERADDRESS j�(7p �tVLr- 121 _ CITYISTATE/ZIP /WpCA 97rZ7/o <br /> CONTRACTOR PHONE E; <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE` <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Ather NUMBER EXPIRATION DATE <br /> GEOGRAPHICALINFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ElNew Well 11Replacement Well. ❑Well Alteration/Modification Other <br /> ❑Monitoring Well(s) #of wells 13Soil Boring(s) #of borings 11Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Weil Renewal 13 Cross-Connection Repair _ <br /> ❑New Pump ❑Pump Replacement ❑Pum' 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 1 Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑Neat Cement(94!b bog 15-10 gal water) ❑Sand Cement sack mix!7 gal water <br /> 13 Bentonite(20%solids) ❑Manufacturer Spec%solids % NameJ ❑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 R Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT T14E 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 1 <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ? <br /> SIGNED TITLE DATE <br /> tz- <br /> bit <br /> MID <br /> jTfq R <br /> Application Accepted By Date `[ Z� o-7 Area Employee ID# <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspectio y Dat �7 WAIVER Received <br /> f <br /> Constructed Well Depth ft <br /> COMMENTS <br /> f} <br /> COMMENTS a dt��i�� O� C e IM{.,,i - (��c�t� a rOu✓lot �-j-4Z 0-y fi- <br /> 41 <br /> PE SC Receivedec Amount Permit/ !. <br /> Codes Into B ash Remitted Date Service Request# Invoice# Well ID# is <br /> Zo st�.c>� -s 0 o 37 <br /> END 43-02.006 WELL PUMP PERMIT <br /> Imaoos <br />