Laserfiche WebLink
39U <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> / <br /> W V rn l I e /`U L,—r—5 TU <br /> CITYlzip S)bc /1 " � ) 9 -r <br /> M <br /> J06 ADDRESS <br /> CROSS STREET / in!'/1 40n ,L APN 055' II—617 PARCEL SIZE /#, LAND USE APPLICATION m m <br /> in <br /> OWNER NAM[ e- I V Fa 1; f I P ZONE��/� 165,53 y <br /> 1 <br /> OWNER ADDRESS I 1 'J 8� CITY/TATE/ZIP �n / I <br /> CONTRACTOR IDP 1 to Pump T I1G_ PHONE J o —9 6 2_ <br /> CONTRACTOR ADDRESS 646 S. California St CITY/STATEIZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE C-57 ik-61 D-09 C Other NUMBER 1055434 EXPIRATION DATE 8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omeslic/Private rJirrigation/Agricultural L Industrial G Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> If different from Ov.nor: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well _ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> %lonitoring Well(s) r of'.veils C Soil Boring(s) . of borings Geotechnical of borings <br /> Oui-Of-Service%Nell Out-Of-Service Well Renewal i Cross-Connection Repair � <br /> New Purno umo Replacement 0 Pump Reoair 7 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method . fatud Rotary Air Rotary Auger C Cable Tool Push Point E Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom - Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel C Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) C Other <br /> Grout Placement Method ❑ Pumped C Free Fall G Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ! Driller C Pump Contractor C Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in C Christy Box C Stove Pipe <br /> PUMP Submersible.] Turbine C 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 COM51ENULON LAWS. <br /> 1 NIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED J: TITLE CEO DATE O D <br /> i <br /> I I I I I <br /> I � . <br /> �r * rr • I� ED <br /> i t l'_ 2020 <br /> P TMENT USE N L Y HEALTH DEPARTMENT <br /> Application Accepted By Date vv Area Employee IDi: <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By t•/;,t� tLt� �(t'.�` Date V-)�511p Ly WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth , ., ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted at Service Re uest# Invoice# <br /> 14591 105-0 <br /> EHD 43.06 <br /> &`04/08 <br /> WELL/PUhIP PERMIT <br />