Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3421A <br /> 68 3421 <br /> NON-REFUNDABLE PERMII-TCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEARFROMDATE ISSUEDof <br /> U <br /> JOB ADDRESS R //f 2G F vA 1,)r n Il t�RICITY/L ` <br /> P U I ) �0 D <br /> CROSS STREET L'11 1 C.r '� V APN E2Z -Cl V J� a <br /> //���� �y L PARCEL SIZE � LAND USE APPIJCATION <br /> OWNER NAME M 1��U f 1 `^�),1,y`�1 �p n PHONE5/q <br /> OWNER ADDRESS 1':z i?y' �, 1Y) C t'I c� r`--f, I� CITY/STATE/LP 1 1 11 Y�-'�'Qr'.T�, r 7C/-A _I ,J�5U <br /> CONTRACTOR �(�I l ��z A0 1��r1l 1 I 1 1, PHONE Di C% .36,`IC-/Q Z7, <br /> CONTRACTOR ADDRESS �• tJ �G X `1 j CITY/STATE/LP Gel 14 C- A �J 6,3 17C <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/Z]P <br /> LICENSE C-57 ,�C-61 U D-09 L Other NUMBER r'+CICI q395 ExPIRATION DATE 3 ) <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Pdvate D Irrigation/Agricultural 71 Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> rI Public Water System <br /> If different from Owner: Water ye em NaM0 one .—or Hnon. um er <br /> TYPE OF WORK New Well CI Replacement Well C Well Alleration/Modification C Other <br /> L'Monitoring Well(s) #of wells _Soil Boring(s) #of borings O Geotechnical #of borings <br /> �n Out-Of-Service Well Out-Of-Service Well Renewal n Cross-Connection Repair <br /> -/,New Pump ❑Pump Replacement C Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary n Air Rotary r Auger n Cable Tool F Push Point n Other <br /> Proposed Well Depth 31;?U It Excavation_I_;in diameter I Open Bottom Yt Gravel Pack/Gravel SJ12�-: _in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_&_in Thickness/Gauge/ASTM Sched CA,1266 7 Steel APlastic D Stainless Steel D Other <br /> Grout Seal Depth_;D O It U Neat Cement(94 Ib bag/5.10 gat wafer) Ksandcement 10.3 sack mix/7 gal water <br /> U Bentonite(20%solids) u Other <br /> Grout Placement Method Pumped U Free Fall a Other J Retardant/Accelerator(name) <br /> PEDESTAL Installed BY Y,Driller u Pump Contractor u Other <br /> Concrete Pedestal c Dirrim ions:Width�ft Length---7 ft Thick in n Christy Box n Stove Pipe <br /> Pu MP X Submersible-Turbine n Other HPC Pump Set ft Standing Water Level ft <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. 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR <br /> INSPECTIONS-PLEASE CALL(209))953-7697 E <br /> SIGNED7 <br /> 7""��?L`���' i', TITLE V t C ' 'n� DATE / 1 I <br /> I 4r <br /> -I <br /> r� <br /> J C�cjV�r <br /> oq(10/,v <br /> 8 ?®21 <br /> TAIA <br /> y e ANT Y <br /> MINT <br /> � 1 <br /> 0-E A MENT U E NLY <br /> Application Accepted Byate Area <br /> -,�� Employee ID# �� f`-ti l Z <br /> Grout Inspection By Date �/ �� ❑ PECI L Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth O ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit! Invoice# WeIIID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> i ?8 <br /> �t rG <br /> EHD 43-00 WELL/PUMP PERMIT <br /> 4130/12 <br />