Laserfiche WebLink
WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzrLTON AVENUE-STOCKTON CA 95205-6231(209)468-3420 <br /> NON-REFUNDABLE PERMIT p WWW.S; OV.Or /ehd EXPIRES'1 YEAR FROM DATE ISSUED <br /> IJ08ADDRESS &z& pa.-,-jK- AVA-N✓E CrtYlZm 5T07C.KT'aN <br /> 9sZrs <br /> n I r D <br /> CROSSSTREET t1VtLNza- iAve APN S 14 ,f.ai PARCEL S. E I b <br /> CT`( F s T�G IC�-p - - D US/���)93 E A'PPLKATION <br /> I # o <br /> OWNER NAME L17-5- A I - z1 z <br /> OWNER ADDRESS /v DQrL�i O(� 5 PHONE\C11STATEIZI Gie—TOA CA Rs' <br /> CONTRACT.. TK 1 C G' '^jT'1' p 21 4L I n!(r /W C Q U <br /> e63 L!I GA X01 PHONE(ClS$J 271- j <br /> CONTRACTOR / <br /> ADOREss A S r Cr1YISTATE/ZIP SI-9 N D/f by. C,4 r7 ZI Z(, <br /> SUBCONTRACTOR/CONSULTANT !") Q)/`I(/ Con-rzw510 N .$P>{C.I LA NE /O)S Fy--3z,-7 Z <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 8371 j-UMPLF25 H(JL£ CITY/STATE/ZIP MI'--f-12-SVI4-L16' rMO Z'// <br /> LICENSE 0-1557 r C-61 0D-09 Other NUMBER 5 T737 EXPIRATION DATE 3� Z2 <br /> BILLING PARTY: D OWNER D CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SANPLING:0 General Mineral/Coliforrn Bacteria(4391)C Dibromochic ropropane(4392)❑Arsenic(4393) <br /> INTENDED UaE DomesNc/Private C Inigation/Agricultural C Industrial 0 Water Quality Monitoring 7 Soil Sampling/Characterization <br /> J Public Water System <br /> If different from Owner ater ystem ams nlact ems or Cris u r <br /> TYPE OF WORK „Ilf New Well I I Replacement Well i Well AfteratiorVModification 14-Nher O 0 IC- r&IJGT7o <br /> 1 Monitoring Well(s) #of wells C S011 Boring(s) #of borings 0 Geotechnical 0 or borings <br /> J Out-Of-Service Well L Oul-CfServlce Well Renewal �j Cross-Connection Repair <br /> New Pum i Pum Replacement D Pum Repair 0 Raise Wet,Casl <br /> WELL CONSTRUCTION� <br /> Drilling Method - ud Rotary 0 Air Rotary C Auger D Cable Tool 7 Push Point D Other <br /> Proposed Well Depth i{S 11 ExcavaWn /Z in diameter C Open Bottom F Gravel Pack/Gravel Size in diameter <br /> 7 Conductor Casing In diameter / Conductor Casing Depth it <br /> Well Casing Dlamet- _In Thlckness/Gauge/ASTM Schad C Steel C Plastic C Stainless Steel r-Other <br /> Grout Seal Depth, 2O ft 0 Neat Cement(94 lb be¢5-10 gal water) C-uand Cement_ 10>1 sack mix/7 gel water I <br /> -1 Bentonite(20%solids) Other -- <br /> Grout Placement Method aTumped -I Free Fell i Other -1 Retardant i Accelerator(name) <br /> PEDESTAL Installed By 0 Driller C Pump Contractor 0 Other <br /> 3 Concrete Pedestal::Dimensions:Width it Length ft Thick In 0 Christy Box a Stove Plpe <br /> 'Pl UMP 1 Submersible D Turbine Other HP Pump Set ft Standing Water Level g <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 1 AM IN COMPLIANCE WITH ALL I <br /> WORKERS COMPENSATION LAWS. <br /> / ,1,1 48 1-10 tit /+�7ANCE NOTICE REQUIRED FOR INSPECTIONS <br /> PLEASE CQALL(209)953-Z6yti <br /> SIGNED TLEOL/ '•)ONf M <br /> V�A�E' t0 17 �G♦' <br /> Fqy� <br /> p FO <br /> 1?071 <br /> ASCC) <br /> R <�ry <br /> FNr <br /> ,�� DEPARTMENT USE ONLY <br /> Application Accepted By c� r< < �- Date_7 %' �% Area fW ���Employee ID# <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Sol Boring Inspecti n By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Ree hved Check#/ Amount PermlU - <br /> Codes Info Cash Remitted Servs I nvolca# wellID1 <br /> l <br /> EHDosae snsnoss - <br /> " WELL/PUMP PERMIT <br />