Laserfiche WebLink
f1 K . WELL/PUMP PERMIT YV�'` 4-G' ,CUA <br /> SANtJOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE-STOCKTON CA 86206-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1(YEAR FROM DATE ISSUED <br /> JOB ADDRESS t " Q clrY¢ , `V w C-4 <br /> CROSS STREET I Y/A AAPN —' y ARCEL$IZE IS' <br /> US <br /> /E APPLICATION# A <br /> OWNER NAME �'/Y pHOplg O <br /> OWNER ADDRESS `` '��y����h{��[I �/ ��� h ( {,� CrTYISTATE/ZIP 1` �9 <br /> CONTRACTOR \j �� �+R/'l \ V�V0 y`I .�,I/�l PHONE M <br /> CONTRACTOR ADDRESS (�(Vti1��(110 WA J w CITYISTATE21P I Cr p 0 T <br /> "-<SUBCONTRACTOR PHONE C <br /> �— "']� <br /> SUBCONTRACTOR ADDRESS CITY/$TATEIZIP � cr 3 <br /> LICENSE 157 C-61 D-09 Other NUMBER EXPIRATION DATE CD ^~ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Townshlp_ Range_ Section_ <br /> INTENDED USE Domestic/Private gation/Agricuftural Industrial Water Quality Monitoring Soil Sampling/Characterization C� aeaeos <br /> Public Water Syst o � <br /> If different from Ownec Water em ama o Name or one Number <br /> TYPE OF WORK ew Well Replacement Well Well Alteration/Modification Other CL! CDD <br /> ♦ <br /> Monitoring Wells) #of wells Soil Boringof borings J of borings ILD <br /> Boring(s) Geotechnical <br /> � CDWell Out-Of-Service Well Renewal Cross-Connection Repair TOca Pump Replacement Pump Repair Raise Well Casing <br /> . <br /> WELL CONSTRUCTION t,r f� <br /> Drilling Method (Mud R Air Rotary Auger Cable Tool Push Point Other (�e/�' <br /> s�I�oe <br /> Proposed Well Depth ft Excavation::��in diameter Open Bottom Gravel PadJGravel Size in diameter C <br /> Condu o Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other in Co <br /> Grout Seal Depth V4 It Neat Cement(94 lb bag/5-10 gal water) }/Sand Cement `b� sack r4xl7 gal water !� C <br /> Bentonite(20%edicts) Other l �� CJ rh <br /> Grout Placement Method ped Free Fall Other Retardant/Accelerator(name) Q' <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dhnenslons:Width ft Length ft Thick in Christy Box Stove Pipe <br /> Pu MP_ Submersible Turbine Other_ _ HP Pump Set ft Standing Water Level it <br /> I HEREBY CERTIFY THAT 1 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 /> MIyNIM)� M 24 HOUR ADV�ANP N/PTIICE'REQUIRED FOR INjS�P-�ECTION -c�PLEASE CALL(209)953-7697 <br /> SIGNED \_i L, � W v 1 J L/( TITLE t^/Z �LJ�VV V� DATE �U <br /> D <br /> ULdi L <br /> 2 � ?014 <br /> HF��QC <br /> �pgR�,U/y�Y <br /> 1 1 j ., V L <br /> �� <br /> /� DEPARTMENT USE ONLY 'I <br /> Application Accepted By IV 1�g -" ic4 Date -2G Area /Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Insp 'on y Date Consi ructed,Well pth R <br /> C MENTSIL <br /> e ?t <br /> PE SC ReceivedasAmount Date I Permltl Invoice# Wan[DO <br /> Codes Info B h Remitted Service Request# <br /> 436 f 6 3W 7 0 <br /> EHD 43-08 WELL HUMP PERMIT <br /> Air"2 <br />