Laserfiche WebLink
A � <br /> WELL/PUMP PERMIT 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> �j CALL 209 953-7697 FOR INSPECTIONS EX�loXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /✓ CITY/ZIP / ' / -` 5 ` m <br /> MOUu D <br /> 0 <br /> CROSS STREET APN- ' PARCEL SIZE -1�!�,j LAND USE APPLICATION# m <br /> N <br /> N <br /> OWNER NAME � � NW <br /> OWNER ADDRESS CITY/STATEIZIP 4II'� <br /> CONTRACTOR H NE <br /> CONTRACTOR ADDRES r CITY/STATE/ZIP (/G <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C TY/ST TE/ZIP o� <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER E (RATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Tow hip Range Section <br /> INTENDED USE ❑ Domestic/Private rrigation/Agric tura) ❑ Industrial ❑ Water Quality Monitorin ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: e r ys em ame Contact Name or one Number <br /> TYPE OF WORK ew Well ❑ Replacement Well ❑ W Alteration/Modification ❑ ther <br /> ❑ Monitoring Well(s) #of wells ❑ Soil B ing(s) #of rings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of- ice Well Renewa ❑ Cross-Connection Repair <br /> ❑ New Pum ❑ Pum Replacement ❑ Pum Re ❑ Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool P sh Point ElOther <br /> Proposed Well Depth a ft Excavation in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> El Conductor Casing in diameter / Conductor C ng De th ft <br /> Well Casing Diameter L? in Thickness/Gauge/ASTM Sched ❑ el lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth�ft ❑ Neat Cement(941b bag/5- gal water) ❑ Sand Cement sack mix/7 gal water <br /> &-ge"ntonite(20%solids) ❑ Other <br /> Grout Placement Method ped ❑ Free Fall ❑ Other ❑ Retardan Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ot❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS PPLICATION AND THAT THE WORK WILNIFY <br /> NE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, D RULES AND REGULATIONS. I ALSO CHAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA ONTRACTORS STATE LICENSE BOARD ANAM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 24 H R ADVANCE NOTICE R IRE NIONS <br /> SIGNED TITLE DATE <br /> 10 <br /> J 3A IN C <br /> _ DEPARTMENT USE ONLY d 51 <br /> Application Accepted Ry Date �.D Area z Employee ID# � ��S <br /> Grout Inspection By Date 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 heck# Amount Permi <br /> Codes Info as Remitted Dat Service Re ue Invoice# Well ID# <br /> 413 q 180 ;1 ` 3 11 " v �� I� 5'a- 6` 80 ed �� ; t <br /> comp!IV IV ... . <br /> by <br /> ;,;=.I: <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />