Laserfiche WebLink
r r <br /> WELL/PUMP PERMIT <br /> JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)458-3420 <br /> NON-REFUND ERMIT CAL 209 9W-7697 FOR INSPECTIONS /EX IRES 1 YEAR FROM DATE ISSUED <br /> .JOB ADDRESS Ca J m <br /> (�,� AAA Q D <br /> CROSS STREET 1 1 I — APN � 1 �� ' PARCEL SIZE �'✓ LAND USE APPUCATON# A <br /> In <br /> ` OWNER NAME � a ' `• . ����PHONE0(((��� OWNER ADDRESS 1n 10 V1 CITY/STATE21\ V CONTRACTOR �,/ r/ ,S _/ PH9 <br /> \J fit <br /> CONTRACTOR ADDRE r "` ----((--_ _H rt ofCIN/STAT�IErZ-IPPIrr.0 -v o <br /> SUBCONTRACTOR PM N <br /> Q <br /> SUBCONTRACTOR ADDRESF• ��C,Irvl$TA�ZIP <br /> LICENSE C-57 V C-01 D-09 Other _ 4UMBE 111 X(_7 lllX/1 EXPIRATON DATE <br /> DOMESTIC:W <br /> L� PUNG: General Mineral/Coliform Bacteria(4391) Dibromochioropropane(4392) Arsenic(4393) r, <br /> INTENDED USE' Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil SamplinglCharacterizatior 11'x1 <br /> Public Water System �J <br /> If odferent fror.Owner. Nater System Name Contaot Name or Pnone Number i <br /> TYPE OF WORK NCw Well Replacement Well Well Aileratien,Moeificabon Other <br /> tt <br /> Monitoring Well(s) #of wells SOII Borings, of borings #o"uorings Geotechnical i - <br /> Out-Of-Service W Out-Of-Service Well Renewal Cross-Connection Repair <br /> New;lump Pump Replaceme Pump Repair Raise Well Casing � <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger CaDle Tec: Push Point Other LA <br /> Proposed Well Depth ft Excavation m clareter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter_.n Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag:5-70 ga!water) Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) Other <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 Lei gty/ ft Thr in .Christy Box Stove Pipe <br /> PUMP V Submersible Turbine Other HP T r`17�'r Pump SS _�: ft Standing Water Leve ft _Zj <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 PENSATION LAWS. (V <br /> t MI UM 24 H UR AD NCE NOTICE REQUIRE FOR SPECTIO/NS-PLEASE <br /> ,t CALL(209) 3- f9� C <br /> SIGNED �� il iq <br /> T LE ��J.Q b�/--e--- DATE n <br /> 1 <br /> W .—y_ <br /> _V P <br /> - z6e <br /> ASG <br /> 05 <br /> 2ft <br /> I NI/1/ZQN(N coUN <br /> U E NLY rHOEpAR M N <br /> EP RTMEN � <br /> Q <br /> Acpi.catlon Accepted By Date ���/ C�I I Area Employee IOx T <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By �'GT/u ��1✓! Date 1 0 to WAIVER Received <br /> Soil Sonng Inspection By Date Constructed Well Depth ft <br /> DPOMENT$ �- <br /> PE SC Received Chec Amount Permit/des Info ash Remitted Date Service Re uest# Invoice# Well ID# <br /> WELL,PUMP?ERMIT <br />