Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTWELLIPUMP PERMIT <br /> ''II/l�l� 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> fYV1Y•REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S aids 1�r <br /> CROSS STREET N <br /> •t CrTY21p M!Ar4ecp) 9't3?b M <br /> 1 1 m <br /> N�TP'pr • y <br /> P APN Z u& Q50, I PARCEL SIZE C/6.U LAND USE APPLICATION# <br /> OWNER NAME PHONE G2-1- gb IG <br /> DD D <br /> OWNER ADDRESS��{ ..�, asX 30 CITYISTATE/ZIP r--r4,Ae klA.4 CA <br /> CONTRACTOR PHONE 52-7— 1 Q <br /> CONTRACTOR ADDRESS 1 p <br /> t ` A CITY/STATPJZIPMy3k"r 62, C <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZJP ' I <br /> LICENSE C-57 D C-61 D D-09 CJ Other NUMBER(Abllo EXPIRATION DATE�i-30�Z.1j <br /> DOMESTIC WELL SAMPLING.A General Mineral/Coliform Bacteria(43911 Dibromochloropropane(4392)is Arsenic(4393) <br /> Il INTENDED USE ?(Domestic/Private Irrigation/Agricultural ❑Industnal Water Quality Monitoring D Sail Sampling/Characterization <br /> Public Water System _ <br /> If tlAferent from Owner Wale,System Name Contact Name m Phone Number <br /> TYPE OF WORK xNew Well D Replacement Well ❑Well Alteration/Modification G Other <br /> Monitoring Well(s) #of wells U Soil Boring(s) "1°rb0r"19e i Geotechnical 0 of bo"nos <br /> Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> New Pump I Pump Replacement 0 Pump Repair ❑Raise Well Casing _ <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary - Air Rotary C Auger [I Cable Tool ❑Push Point 0 Other <br /> Proposed Well Depth-36) ft Excavation 12- T in diameter C Open Bottom ;t Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad 2-G+y ❑Steel :'Mastic I1 Stainless Steel I Other <br /> Grout Seal Depth 7_0 ft Neat Cement(94 Ib bagi,5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Xpumped C Free Fall C Other G Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ump Contractor Other <br /> _Concrete Pedestal Dime slons:Width_ Length ft Thick n fl Christy Bo: Stove Plpe <br /> Pump Set h Standing Water Level ft <br /> PUMP r'Submersible-]Turbine Other. <br /> Hp <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL TI 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 /> MINI M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) <br /> TE <br /> TITLE ��— <br /> SIGNED <br /> R E,4-. <br /> Mq V F� <br /> X04 Q ? ?020 <br /> L// <br /> TOE q�CO�NTr <br /> 0 <br /> /vr <br /> / (DEPARTMENT USE ONLY <br /> 7,7 /l r <br /> Li 4, Date S Z) Z,-., Area Employee ID# -� <br /> Application Accepted By �I���L� ❑ //SPECIAL Well Permit <br /> Grout Inspection By C l'u �`'Y1 �-�`l' Dale_ _ <br /> Dale_�_ ❑ WAIVER Received <br /> Pump Inspection By ft <br /> Date Constructed Well Depth <br /> Soil Boring Inspection By <br /> COMMENTS - <br /> Permit/ Invoice# Well ID# <br /> PE SC Received Check#/ Amount Date S rvice Re uest# <br /> Codes Info ash Remitted <br /> Lt3ca 7 <br /> �......,,. •nrn• //\J� //_���Q WELL RUMP PERMIT <br />