Laserfiche WebLink
a <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL. TH DEPARTMENT 600 EAST WAIN STR OCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J � As4i�~ `� - CITYMP <br /> D <br /> CROSS STREET 4-A^.) APN - ARCEL SIZE LAND USE APPLICATION Of <br /> °o <br /> OWNER NAME _ l_._"FY e L`Sz-U^) OL-® D I i Z3 PHONE <br /> OWNER ADDRESS 335 6 C, 4^'-AV"eYL C49V/VI CITY/STATEZP //{{ <br /> CONTRACTOR raiz-s 1-'-L- PHONER(b �J� • t o o <br /> CONTRACTOR ADDRESS - Yy 1)&tj gfa-ee-/G /0-I CITY/STATE/IJP .,y/ <br /> SUBCONTRACTOR PHONE <br /> SSU,BCONTRACTOR ADDRESS �r CITY/STATEMP h q <br /> n f) pp W NSE I I C-57 I I C-61 I I D-09 XI Other C�+r=Fa� NUMBER &0 3 fo i b EXPIRATION DATE V J 3 f p.d 10 <br /> �UuI 15 = GRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br /> rel 1 DED USE Domestic/Private ❑Irrigation/Agricultural C Industrial 7 Water Quality Monitoring 7 Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Omer: a er ys em Name Conta ame or one um er <br /> OF WORK 7 New Well ❑Replacement Well C Well Alteration/Modification i6ther <br /> 7 MonitoringWell(s) of wells ❑SoilBoring(s) #of borings ❑Geotechnical aofborings <br /> Vv� M -1 Out-Of-Service Well C Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> {�}t :1 New Pum -1 Pump Replacement C Pump Repair <br /> L� WELL CONSTRUCTION <br /> Drilling Method :1 Mud Rotary a Air Rotary C Auger ❑Cable Tool ❑Push Point X Other ILIAC—O V t'-- <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter -T <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel C Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) :1 Other <br /> Grout Placement Method u Pumped a Free Fall a Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 7 Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 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 /> INI M 24 H04R ADVANCE NOTICE REQUIRED FOR INSPECTIONS +� <br /> 6'P"` DAT <br /> cE I�- d <br /> SIGNED TITLE <br /> DE PjA RT ENT US N L Y <br /> Application Accepted DateArea Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By �? _ Date l d Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date PermifJ Invoice# Well ID# <br /> Codes Info B s Remitted Service R nest# <br /> 5A o .S4Od ll0 <br /> EHD 43-06 WELL-PUMP PERMIT <br /> 928/07 <br />