WP0038761 - Laserfiche WebLink

Home Browse Search

i ELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARI MENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 4684420 NON-REFUNDABLE MIT CA L 209 953'7-7 97 FOR INSP NS EXPIfZES 1 Y R FROM DATE ISSUED JOB ADDRESS c,"OPP'7�, /t / go�CROSS STREE Y � N �^ D�1 ARCEL SIZEr ILUI.�AND USE APPLICATION0 OWNER NAME r ej 1 yIU I t PHONE ''') - ` SG. OWNER ADDRESS O CrrY/$TATEILP 01 CONTRACTOR CANEPA AND SONS, 1NC.1 PHONE (209) 532-1136 CONTRACTOR ADDRESS 14384 CUESTA COURT CITY/STATE/ZIP SONORA, CA 95370 SUBCONTRACTOR I PHONE SUBCONTRACTOR ADDRESS CITY1$TATEr7JP LICENSE ECC -57 0 C-61 ❑ D-09 D I011 ier NUMBER 425749 ExPIRATION DATE 7/31/2020 DOMESTIC WELL SAMPLING: D General Mineral/Coli orm Bacteria (4391) ❑ Dibromochloropropane (4392) D Arsenic (4393) Ir.rzENDeD USE ❑ Domestic/Private . rngation/Agri ultural 0 Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization 0 Public Water System It ®tterent from Owner. I Water System Name Contact Name or Phone Number TYPE OF WORK )<New Well D Replacement Wei 0 Well Alteration/Modification 0 Other ❑ Monitoring Wells) # o wi IIs ❑ Soil Boring(s) a of borings ❑ Geotechnical # of borne 1 O Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair 0 New Pump ❑ Pump Re laceine it 0 Pump Repair D Raise Well Casin S WELL CONSTRUCTION I Drilling Method KMud Rotary ❑ Air Rotary 0 A iger n Cable Tool 0 Push Point ❑ Other H Proposed Well Depth�m ft ExcavaiIor 26 in diameter ❑ Open Bottom Gravel Pack/Gravel Size _ in diameter (Conductor Casing 30 in d6 eter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gault STM Schad • Z Steel 0 Plastic 0 Stainless Steel 0 Other Grout Seal Depth Sib ft ❑ NeatlC ent (94 lb bag/5-10 gal water (Sand Cement 10.35K sack mixl7 gal water D Bentonite (20% sofids) ❑ Other Grout Placement Method Pumped 0 Free Fall Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller XPum0 C ntractor ❑ Other 0 Concrete Pedestal DDimenslons: tdth It Length It Thick in D Christy Box ❑ Stove Pipe PUMP 0 Submersible0 Turbine 0 Othe} HP Pump Set It Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED ItH S APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, NO RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COIV�ENSATION WS. 1 8 HIDVANC NOT CE REQUIRED 1`07INP !/-CTI !a . PPLEA'SE CALL (209) 5 76 7 SIGNED TITLE (" `''/ DATE k Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS 'MENT UGS/E gNJ,.Y -,Date ///L Area Employee ID# _ Date ❑ SPECIAL Well Permit Date ❑ WAIVER Received Date Constructed Well Depth ft PE SC I Received I Check#! I I Amount I Date I PerrniV I (nvoic Codes 1 Info B;u Cash Remitted SQrvice Reauest # �J Ali EHD 43-96 reWsaC 4/74!78 L/r WELL /PUMP PERMIT