Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1yYEAR FROM DATE ISSUED <br />y <br />' <br />�f <br />f� <br />d <br />Joe ADDRESS 1 <br />C' V^ <br />! Cm21P <br />C',q1 ! 1 <br />- (' C r <br />CROSS STREET <br />APN <br />PARCEL SIM / f_ / <br />LAND USE APPLICATION A <br />�7 <br />a lc Z ,O <br />z <br />C }� <br />321f D`- <br />OWNER NAME <br />rG/� <br />!Le I, <br />PHONEI-Oct `!51 <br />OWNER ADDRESS S'C'1�,' L.�'Cy <br />W, Iti' <br />Crry/STATE/ZIP 1i <br />Iye/V�!r�'l"n'; r 3�: 7 <br />• 1 <br />CONTRACTOR <br />) - <br />PHONE SI _ <br />CONTRACTOR ADDRESS <br />LU <br />�19 e CRYISTATE/ZIP <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATE/ZIP <br />LICENSE G-57 -61 <br />- D-09 Other <br />NUMBER <br />ExPIRATKIN 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 Waier byStOM Neme conted NaMe or Phom Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification r Other <br />Monitoring Well(s) # of wells 7 Soil Boring(s) it of bonngs Geotechnical #Of bofi"os <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary ' Air Rotary Auger Cable Tool ' - Push Point Other <br />Proposed Well Depth k Excavation in diameter I Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth k <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched •, Steel Plastic Stainless Steel '_ Other <br />Grout Seal Depth ft Neat Cement (941b bag/5 10 gal water) Sand Cement sack mIx/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall - Other -. Retardant / Accelerator (name) <br />PEDESTAL Installed By t -Driller Pump Contractor - Other <br />- Concrete Pedestal Dimensions: Width ft Length k Thick in - Christy Box Stove Pipe <br />PUMP wSubmersible Turbine Other HP Pump Set (2 /n n k Standing Water Level IJ/') it <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 />DEPARTMENT USE NLY } <br />/� Date S ra Area �7 Employee ID#. <br />Application Accepted By <br />Grout Inspection By Date C SPECIAL Well Permit <br />Pump Inspection By Date �' 21 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth it <br />COMMENTS A1p4j/jr' N" AAW Fy0 -1 x;-37 <br />PE SC Received h <br />Codes Info B <br />Amount <br />Remitted <br />ate <br />PermiU <br />Service Re uest # Invoice # Well ID# <br />L) <br />S"j <br />EMD 4306 WELL /PUMP PERMIT <br />4/30/12 <br />