Laserfiche WebLink
dI <br /> ' WELLIPUMP PERMIT ) <br /> AN."UA-UII COUNTY EAVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMI A 209 W- 697 FO I PECTIONS EXPIRES 1 YEAR FROM <br /> DATE ISSUED <br /> JOB ADDRESS lt 1412 CITY/ZIP- &I t' �'7 G1�`� In <br /> CROSS STREET N' rA �YHAp/I"t APN Q E)S f6 0I PARCEL SIZE�t� LAND USE APPLICATION# <br /> OWNER NAME ' eIt-r <br /> D <br /> I.,, PHONE <br /> OWNER ADDRESS A N L CITY/STATE/ZIP <br /> CONTRACTOR r�-"'ice"' Jul�t+ ( r" l PHONEL2 <br /> (�r <br /> CONTRACTOR ADDRESS +v CITY/STATED., � I xl .k <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT,�E/r7ZIP <br /> 011 <br /> LICENSE �-57 ❑C-61 D D-09 ❑Other NUMBER.- ����S EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ N <br /> INTENDED USE >df DomesticlPrivate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner; er ys em Name o a ame or one um er <br /> TYPE OF WORK 7<New Well D Replacement Well ❑Well Alteration/Modificabon ❑Other <br /> ❑MonitodngWell(s) #of wells ❑SoilBoring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 7KNew Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth�(� ft Excavation In diameter ❑Open Bottom ravel Pack/Gravel Size _in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter i) in Thickness/Gauge/ASTM Sched L DO ❑Steel j01astic ❑StainI s Steel ❑Other <br /> Grout Seal Depth 00 ft ❑Neat Cement(94 Ib bag,5-10 gal water) SI�and Cement sack•mix/7 gal water <br /> ❑Bentonite(20%solids) D Other <br /> Grout Placement MethoqPI!JcPumped ❑Free Fall D Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller ❑Pump Contractor ❑ Other ^ <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe i \ <br /> PUMP ❑Submersible❑Turbine ❑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 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 <br /> SIGNED �� �' TITLE �pt/'-' DATE <br /> i 1 1 <br /> '/ p <br /> UI <br /> (/ LT N <br /> f <br /> i. <br /> - � 4 <br /> DEPAe T ENT SE NLY <br /> Application Accepted --,,�'�/ e/ <br /> r Date Area Employee ID#t <br /> Grout Inspectio Date vr' ❑ SPECIAL Well Permit <br /> Pump Inspect n By Date:�� El WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS O i <br /> PE SC Received 'Check Amount Date Permit/ Invoice# Well 1D# <br /> Codes Info B Cash Remitted Service Request# <br /> EH D <br /> 43-06 WELL/PUMP PERMIT <br /> 9/28/07 <br />