Laserfiche WebLink
'WELL /'PUMP PERMIT � ,j <br /> SAN,JOAQUIN COUNTY ENVIRONMENTAL HEALTHDr RTMENT 304 E WEBER 1�3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON—REFUNDABLE PEIRMIT 0 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rA <br /> JOB ADDRESS CITYIZIP <br /> 4 tr <br /> Q`� n--_ _, 12-11 <br /> �7 CAPPLICATION t;—w R <br /> CROSS STREET U V� n�`K / �•�I Ala ���If/1/)(�YcPAI�CE�S ZE /LAND USE �6 � <br /> OWNER NAME C �� i4h'l/L y ,w fJff - JC.�' PHONE a6� yip�� <br /> ee r zQo - <br /> OWNER ADDRESS CITYISTATEIZIP <br /> k <br /> CONTRACTORF L- PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> SUBCONTRACTOR " PHONE <br /> SUBCONTRACTOR ADDRESS - �'4 CITY/STATE/ZIP <br /> 7i <br /> LICENSE ❑C-57 p C-61 ❑D;09 ❑Other NUMBER EXPIRATION DATE <br /> Ih 'I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private 'gation/Agricultural Ll Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> ltdifferent from Owner: Water System Name Contact Name or Phone Number <br /> u <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Wel!Alteration/Modification ❑Other <br /> ❑Monitonng Well(s) #of wells L3Soil l3oring(s) °f borings 13Geotechnical of borings <br /> t-Of Service Well El Out-Of-Service Weil Renewal ❑Cross-Connection Repair <br /> ❑New Pum ❑Pum' Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method Q Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation r! in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth fi <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic 13 Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) 11Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑:Specs Submitted <br /> Grout Placement Method I1❑Pumped ❑.Free Fall ❑Other ik ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller] ❑Pump Contractor '❑ Other <br /> ❑Concrete Pedestal Dimensions:Width0 ft Length ft Thick in ❑Christy Box ❑:Stave Pipe <br /> PUMP ❑Submersible ❑Turbind ❑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 ACTIVEWITHTHE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. i <br /> d MINIMUM <br /> M2224�llHOUR ADVANCE NOTICE <br /> -�REQUIRED FOR INSPECTIONS <br /> SIGNED /NL a faWi2ma'L TITLE DATE �� '�/'��Z✓ <br /> t <br /> I <br /> s r <br /> () <br /> I � <br /> - I <br /> 7 DEPARTMENT USE ONLY <br /> Application Ace �i 'sl -d�' Date/' ���G� Area Employee'ID [,� i <br /> Grout Inspection iti Date ❑ SPECIAL Well Permit / <br /> ❑ WAIVER Received <br /> Pump Inspecti B " <br /> Constructed Well Depth Its <br /> " :/ (/ i <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Into B :,Cash Remitted f. Service Request# <br /> ;r <br /> / ?� �-� <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 112712005 a! ' <br />