Laserfiche WebLink
f K <br /> WELUPUMP PERMIT 1 , <br /> SAN JG!,OUIN COUNTY ENVIRONMENT'hL HEALTH DEPARTMENT V' <br /> EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS i U� L/► (� Av Q-- <br /> p C (� Q,, CITY/ZIP_ <br /> CROSS STREET � "^�" 1p J c�G✓, )4- A�PN_ 1719 — 1�� D?)PARCEL SIZE W,,Il I LAND USE/APPLICATION# <br /> OWNER NAME �S ec Ell.. AT L- PHONE 1 c �7 v r"`� y <br /> OWNER ADDRESS C 60 -�+� !�� 7544 'C�% CITY/STATE/ZIP ���s (24 <br /> CONTRACTOR H�WW{�'9- erp 60tvhLoPHONE 2 ,P 7 "" -/07�1� <br /> CONTRACTOR ADDRESS _ &I-Z ) �� ed" CITY/STATE/ZIP �`�F ► �jZl� <br /> JL <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ,/ <br /> LICENSE �C-57 i C-61 I D-09 Other NUMBER 66PGf2-7 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y _. Township Range Section <br /> i INTENDED USE Domestic/Private /('irrigation/Agricultural n Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Pubic Water System <br /> If different from Owner: Water ystem ame t e hon b r <br /> TYPE OF WORK New Well I Replacement Well Well Alteration/Modification h <br /> Monitoring Well(s) #of wells Soil Boring(s) #ofr rings ++ eotechnical #o borngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal F[$ rQ�s e�q' 1 ire wi flout <br /> New Pump -)</Pump Replacement Pump Repair %'. <br /> WELL CONSTRUCTION <br /> r� <br /> Drilling Method Mud Rotary ❑ Air Rotary Auger � Cable Tool a Push Pointb Y�'Otonmpntal H'Cai(l, C-Msior <br /> Proposed Well Depth ft Excavation in diameter rI 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 1 Steel 1 1 Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-f0 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller I Pump Contractor Other <br /> oncrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box I Stove Pipe <br /> PUMP Submersible Turbine Other HP— Pump Set it Standing Water Level <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- PLEASE CALL(209//)95�3--76977 <br /> SIGNED r �/ /�"� TITLE DATE 6)_2 <br /> t <br /> Rt <br /> _ 1 <br /> JUAl 2 <br /> A <br /> --N1 ein I JN ry <br /> N <br /> A ^A DEPARTMENT PSE ONLY I <br /> App!ic tion accepted By /\- Date ��Ol ti� ` < < Area �� ` �� Employee ID#�� <br /> Grout Inspection By Date LI SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check Amount PermiU <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> tklit 0,50 Lb I I g I1?' 5400 SS-- <br /> EHD 43.06 WELL/PUMP PERMIT <br /> '70112 <br />