Laserfiche WebLink
y.Wr-km„l 5 U-7-16 A5� <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONSC EXPIRES 1 YEAR FROM DATE ISSUED <br /> r/� //,�� f j//7 �J/ /J� �//, y/r�r (/�- /7(�) to <br /> JOB ADDRESS _ppY(41 t/� • `� W CITY121�/ra v • 7 i J 53ZO n <br /> GROSS$TREE? PL.+ APN_ '-Q • PARCEL SIZE y L 11//31IUSE AP LIGATION# a <br /> TOWNER NAME ", I - / [. (/"O�NL+Eq <br /> OWNER ADDRESS � /ns V ) TTY STATE P ` C4 ! y <br /> CONTRACTOR �' {./ t/Ii U /,�(.,HHONE i/ �-L Z10 C� <br /> CONTRACTOR Ai DUp ss Tu ` i CITIISTATE , ` '" tL <br /> SUBCONTRACTOR 1v 1A Ir <br /> /L/,�F _ PHONE <br /> SUBCONTRACTOR ADDRESS f I ] CITYISTA,�TEEIrZIIP}� •• j <br /> LICENSE Y, C-57 C-61 D-09 Other (� NUMBe &w lV V EXPIRATIONDATE j r/ <br /> GEOGRAPHICAL INFO ATION: Coordinates X Y Township Range Section_ <br /> INTENOLDUSE DomesticlPrIvale IrrigationlAgricultural Industrial Water quality Monitoring Soil SamplinglCharacleriaatlon <br /> Public Water System <br /> 4 different horn Owner: Vvalef ys m I hoc rl3rne or Prone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other C� <br /> #oibodngs <br /> Monitoring Well(s) #of wells Soil BDring(s) Geotechnical #ofbcnngs <br /> Out-Of-5ervlce 5011 Ow-Of-Service Well Rene'wtil Cross-Connection Repair <br /> New Pump V Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other �' 1 <br /> Proposed Well Depth ft Excavation in diameterOpen Bottom Gravel PacklGravel Size In diameter "\ ` <br /> Conductor Casing in diameter I Conductor Casing Depth If �( <br /> Well Casing Diameter_in ThicknesslGaugelASTM Sehed Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-14 gal water) Sand Cement sack mirf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:W Idth ft Le th _ ft Thick in Christy Box ' Stove <br /> PUMP Submersible Turbine Other HP Pump 5 It Standing Water Level fl <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 A <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL tL1 <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOVNNfS�PE/CjTI/OWNS-PLLEyA�SSE�CALL(209)9 -76]97 _V <br /> SIGNED TITLE �'f Y L(Pal �I 4 1! DATE t <br /> NIVED <br /> +} 2016 <br /> t' L HEALTH <br /> D1 L <br /> t��GES <br /> 7-7-71 <br /> G <br /> N <br /> PAIRTM ENT U E O N L Y <br /> Application Accepted Byti —S _ .ale i147 Area '!_ Employeeto#L�Ili <br /> Grout inspeclien By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Bering Inspection By Date Constructed Well Depth tt <br /> COMMENTS <br /> PE SC Received Check#1 Amount Permit/ <br /> Codes Into B _ Cash Remitted Date Service Re uest# Invoice# Well 111310 <br /> ! KZ 23 6?3 �RG� 1 <br /> EHD 43-06 WELL(PUMP PERMIT <br /> 4130,2 <br />