Laserfiche WebLink
WELL/PUMP PERMIT <br /> E SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3 10 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Gy/' (/.-� C 1� t� �(.��r! /�^ to <br /> JOB ADDRESS ISI I V L ��J T c'Y)� �J ) CITY/LP I \`L\4 \ C) C� �� m <br /> CROSS STREET-.W t� I�U./\�� ���-1 APN` O o.7 V�//� ` ARC 1EL SIZE LAND USE APPLICATION# z <br /> OWNER NAME 1\ C�1 C�1� ��'�7'�'�ti�.T 1 n C�y1�� !�1C11'/1t C v1 L�Y)CC�HONE �'� �� — LI ' •" <br /> OWNER ADDRESS `I CfTY/STATEZP <br /> CONTRACTOR \j 1 7 ` 1` I PHONE <br /> CONTRACTOR ADDRESS P r) CRY/STATEJLP C /'� q 5 C-3,2 <br /> SUBCONTRACTOR PHONE <br /> (SUBCONTRACTOR ADDRESS CITY/STATE/7JP <br /> LICENSE C-57 j<\C-61 -D-09 . Other NUMBER C� �3 EXPIRATION DATE <br /> 7-31 - ��� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE DomesbcfPhvate - Irrigation/Agricultural Industrial _Water Quality Monitoring _Soil Sampling/Characterization <br /> Public Water System �� <br /> If different from Owoer. a er ys a me or om o— o ene um r A_ <br /> TYPE OF WORK ,New Well Replacement Well Well AReration/Modification Other <br /> Monitoring Well(s) #of wells Soil Borings) 't°i s0°rte _ Geotechnical •of brings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ,,',New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION ✓ 2019 <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point other _ FAn- Q(//N ,1J <br /> Proposed Well Depth :� G ft Excavation��in diameter Open Bottom x Gravel Pack/Gravel Size I/4_ in O/�/M COON <br /> . Conductor_Casing in diameter / Conductor Casing Depth ft iPZ) Tq( <br /> Well Casing Diameter (,-_in Thickness/Gauge/ASTM Sched C1 C r 4' Steel ;e Plastic Stainless Steel Other MENT <br /> Grout Seal Depth I G(; ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%sotids) 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 4 ft Length R Thick SL in Christy Box Stove Pipe <br /> PUMP Submersible Turbine -Other HP Pump Set ft Standing Water Level I ft <br /> 1 HEREBY CERTIFY THAT 1 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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED p7 ca T tiJ�� TITLE ,C C ��r' I C'n DATE -11SCII 19 <br /> I <br /> 47— <br /> u � <br /> v <br /> DrfRTMENT USE ONLY p <br /> Application Accepted By C`ti�–�--I Date Area Employee ID# �t 'Zk <br /> Grout Inspection Bymmh2ifiA� ,y Date D SPECIAL Well Permit <br /> Pump Inspection By bf�` ' �( 'I�+l Date t ! WAIVER RBC@IV@(1 <br /> Soil Boring Vtspectio By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received (Checlil Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> �t3•G I SvqY7 L -a1 �I-I�i N X03 (0 <br /> u 5`C i Lf l W OJ <br /> EHD 43-08 WELL/PUMP PERMIT <br /> V30/12 <br />