Laserfiche WebLink
WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS r �T f� y��SJ✓Ll( n CITY/ZIP e-n�s C� �A C� <� <br />CROSS STREET C J�'^�+\ APN i `C4 " 60 r _PARCEL SIZE LAND USE APPLICATION # / <br />OWNER NAME "^l lJ \l i �� IJ�S `� 4�1 - PHONE `f0J0/ <br />OWNER ADDRESS V !r�K-rJ OK_ w v^ F+l .-C CITY/STATE/ZIP <br />l� n„ yy�� ,,�� ,�� j` v �% (,s' <br />CONTRACTOR �, kA r �LZ ( lk q) � PHONECZ tit) � l u( /J L 0(-) V <br />CONTRACTOR ADDRESS 4/y J0*3 Z- ko CITY/STATE/ZIP ��C-)L V&, I CI <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS / CITY/STATE/ZIP <br />9 -/Other-1'LICENSE C-57 C-61 D-0 � EXPIRATION DATE <br />NUMBER <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: Water System Name CrViKhone Number <br />TYPE OF WORK I New Well Replacement Well Well Alteration/ModificationOther l <br />k of borings _ # of borings <br />Monitoring Well(s) # of wells Soil Boring(s) e <br />ftj6�� <br />ut-Of-Service Well Out -Of -Service Well Renewal Cross-Connec i ]� <br />New Pump Pump Replacement Pump Repair Raise Well Casin L <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />ento"20%ds) Other <br />i .. -rr <br />Grout Placemekt .M I e Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller ! Pump Contractor Other I <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in r Christy Box Stove Pipe I <br />PUMP I Submersible Turbine i Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CEIRTIFY 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. 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 COMPENSATION LAWS. <br />M UMU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 7'697 <br />j <br />SIGNEDTITLEo DATE <br />DEPARTMENT USE ONLY <br />Arp!icat!or. Accepted By -- <br />Grout Inspection By <br />nate___ <br />Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS 1 C, — 4 I 4 L <br />mm <br />D <br />O <br />M <br />m <br />m <br />rn <br />l'4" ` / (� pp{/� <br />Area �/ l ��Employee ID# l a S� 1 " ' �- <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />4— <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Permit/ <br />Date Service Request # <br />In #JL <br />tl� <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />