Laserfiche WebLink
WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 . (209) 468-3420 <br />11WIN-Rtr UNMAULt rt11hut UALL LVy yOJ-109/ FUK INSHEGIION5 CAh9KtJ 1 T EAR FROM DATE ISSUED <br />ADDRESS Z�oja`j <br />F.R.SS <br />CITYILP Tra t� GA q5}�3C)4 <br />QWS/',rUnp} ^L%he,I <br />STREET _L/ \I t 1 1` OVA d APN _ 1< O Vy <br />PARCEL SIZE N A LAND USE APPP�LLICCATION # `� A <br />`O, <br />Q1 <br />OWNER NAME _ CA Y1 Oso LJ CO 4/nrjl+1-A PHONE <br />�/J 1,T <br />OWNER ADDRESS _ _Il _ Q � O [, R A Z1 { 'j +,Dyi Ave e <br />CITY/STATE/ZIP -5 ' p C, tom.; -o n� CA a5 7-05 <br />CONTRACTOR U e-o'FE X___ it l I <br />Iee <br />_.('PHONE C\ --I -i �-/8,n`{ D <br />s\ <br />CONTRACTOR ADDRESS 1 J `O M A a c.rrD r <br />CITY/STATEJZIP ) I X V Y C <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTJATE/ZIP <br />./r ^� J /� <br />LICENSE XC -57 11 C -fit D D-09 C Other NUMB� <br />ER q5 1 Z(0-7 E%PIR- <br />ATION DATE / ��Z-0 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section <br />WENDED USE D Domestic/Pnvate D Irrigation/Agricultural U Industrial D Water Quality Monitoring if Sampling/Characteriza6cn <br />D Public Water System <br />If calf—nt from Owner.via., system acre Contact Name or PInore Number <br />TYPEOF WORK L New Well J Replacement Well U Well Alteratien/Modification _I Other ����tttt���_ <br />C Monitoring Well(s) N of wells D Soil Bonng(s) of 5onrgs-eotechnlcal n of nc-96 <br />L Out -Of -Service Well U Out -Of -Service Well Renewal ; CrosS-CoCection Repair <br />LJ New <br />Drilling Method>(Mud Rotary C Air Rotary -Auger CC_able Tool C Push Point D Other <br />It /o <br />Proposed Well Depth 30 -50 Excavation t"{ — ( in diameter Open Bottom D Gravel Pack/Gravel Size in die <br />Y, Conductor Casing <br />_�__ in diameter / Conductor Casing Depth i—to ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Schad D Steel C Plastic C Stainless Steel C Other <br />Grout Seal Depth ft D Neat Cement (94 Ib bag3-10 gal water) C Sand Cement _ _ sack mix/7 gal <br />D Bentonite (20% solids) D Other <br />Grout Placement Method C Pumped L Free Fall X Other fl Retardant/ Accelerator (name) <br />PEDESTAL Installed By rl Driller fl Pump Contractor Other <br />-1 Concrete Pedestal FDimensions: Width it Length it Thick in fl Christy Box F Stove Pipe <br />PUMP U SuhmersibleO Turbine O Other HP Pump Set it Standing Water Level 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 ORDI(iANCES, 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 COMPENS N LAWS. <br />IyN�f /�My; OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE /CALL (209) 953-7697 <br />SIGNED-/''�'I�T-�i TITLE r0 e- (r ( e e45ATr 1011 t'I I 1 q <br />Wpm <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■KIWI • ' • <br />■■■■■■■■■■■■■■U■■■■■■■■■■■■■■■■■■■■■■■■■■1!!�I • • • <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■iliiu •.., <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />Application Accepted By <br />..te i e <br />Grout Inspection By Date C1 SP(EciAL Well 'Permit <br />Pump Inspection By Date 0 WAIVER Received <br />DepthSoil Boning Inpection Date Conistructed Well <br />COMMENTS�. <br />PE Sc Received <br />Codes Info B <br />ChecM Amount Date Permttl Invoic <br />Cash Remitted/ Service R uest # <br />0 <br />j -AL JL�j-AL%LkVjLjLf <br />S <br />EHD 43-06 <br />4136/12 <br />WELL /PUMP PERMIT <br />