Laserfiche WebLink
I k vj-31 -16 OSw. <br /> WELUP�IMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PECR�MI✓T/ CALL 209 53-47697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L L G /�-'' CITY/ZIP <br /> CROSS STREET APN PARCEL SIZE / LAND USE AAPPLICCAATION# a <br /> OWNER NAME sLL� r���^^/`S S'�✓ PHONE CEJ CT'Z 00*2_S- <br /> OWNER ADDRESS ✓i`'p, CITY/STATE/ZIP (� �/ �` <br /> CONTRACTOR �S�1 g, �/�-�l PHONE-33/ '-C/ 7ZJ <br /> CONTRACTOR ADDRESS /- r✓ /ter// L�d- CITY/STATE21P C+ i�-�'LIHG- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE )KC-57 ❑ C-61 F1 D-09 -' Other NUMBER37! Jg> EXPIRATION DATE b r/ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section_ <br /> INTENDED USE ❑ Domestic/Private rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System . <br /> If different from Omer: Contact ameor one Number <br /> TYPE OF WORK `<4ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) If of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal C Cross-Connection Repair <br /> >41ew Pump ❑ Pump Replacement n Pump Repair I i Raise Well Casinsi <br /> WELL CONSTRUCTION <br /> Drilling Method<Mdd Rotary ❑ Air Rotary C' Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well DepthW. ft Excavation IS in diameter ❑ Open Bottom )KIfimvel Pack/Gravel Size In diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamete In Thickness/Gauge/ASTM Schad 1-70 ❑ Steel )Odlastic Stainless Steel ❑ Other <br /> Grout Seal Depth S ft ❑ Neat Cement(94 lb bag/5-f0 gal water) >,"and Cement 4d4l sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement MethodAQPumped ❑ Free Fall f t Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller ❑ Pump Contract ❑ Other <br /> Li Concrete Pedestal 'Dimensions:Widthor ft Length It Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP VICSubmersible o Turbine [I Other HP Pump Set It Standing Water Level tt <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. 1 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 /> MINIju�U 4 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209) 53-7697 <br /> SIGNED �� �(a-.. TITLE OCJJif'�YL DATE <br /> 3H <br /> Nl Cj 3 <br /> bg <br /> n <br /> ZL <br /> VVI <br /> I ILL L <br /> "t t <br /> DE ARTMUS--� Y <br /> Application Accepted`E1y_� 1r,7�A�h �`+'�� _ Date <br /> 3 � Area tYl.�L''/ Employee ID# Fu Grout Inspection By Date ❑ SPECIAL Well Permit -__ <br /> Pump Inspection By Date El WAIVER Received <br /> Soil Boring Inspection By Date Constructed Vyell D th ft <br /> COMMENTS n <br /> PE SC -Received he Amount Date Permit/ Invoice# Well 10# <br /> Codes Info B ash Remitted Service Request# <br /> 7 <br /> e 0-7119-2 <br /> v <br /> EHD 43-06 r W ELL/PUMP PERMIT <br /> 4/30/12 <br />