Laserfiche WebLink
T1n'-P�4� 5((4 <br /> WELUP MP OERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)466-3420 <br /> NON-REFUNDABLE PERMIT !� CALL 209 95[3--7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS `J J�(/ J/LC Zl s 4`001 <br /> / H <br /> / - . CITY/ZIP D <br /> CROSS STREET �/L/CJ/�-9 CN APN W PARCEL SIZEC S LAND USE APPLICATION If a <br /> OWNER NAME c���(� /� PHONE 6O3—_r3 o y <br /> OWNER ADDRESS j ♦ CITY/STATE/ZIP- <br /> CONTRACTOR 2V t)4 GA"s Lo/la.-c/ PHO _J2� L <br /> CONTRACTOR ADDRESS & i g%Z-Jr? CITYJSTATE21P <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ><C-57 C-61 I.1 D-09 'L Other NUMBE3C c �`� EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section_ <br /> INTENDED USE ><Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System ame Contact Name or Pliome-Tum-Fer <br /> TYPE OF WORK blew Well ;00eplacement Well ❑Well Alteration/Modification n Other <br /> ❑ Monitoring Well(s) If of wells ❑ Soil Boring(s) u of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> >CNeW Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method-4-Mud <br /> ddlRotary 11r <br /> Air Rotary l Auger [I Cable Tool Push Point D Other <br /> Proposed Well Depths_0 /-r it Excavation � in diameter ❑ Open Bottom .aQGravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter C_ in Thickness/Gauge/ASTM SChed7_20 ❑ Steel S44astic ❑ Stain ss Steel ❑ Other <br /> Z <br /> Grout Seal Depth O-O .ft ❑ Neat Cement(94 Ib bag/5-10 gal water) _5gSand Cement 8� 3 sack mbd7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method dumped ❑ Free Fall n Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Q Driller Li Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width it Length ft Thick in F1 Christy Box El Stove Pipe <br /> PUMP ubmersible❑ Turbine Other HIP 'L 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 COMPENSATION LAWS. <br /> M�24 F�QUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED /- �_ TITLEO,tj"I- DATE <br /> 2 <br /> O <br /> z <br /> a <br /> LL <br /> D � ARTM ENT U /E� LY <br /> Application Accepted By Date 7 <br /> Area Employee ID# Zu <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 Check#/ Amount PermiU <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 7I 3 N 5 6 <br /> Sa <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/3&12 <br />