Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAMLTON AVENUE-STOCKTON CA 95205-(209)46"420 <br /> NON-REFUNDABLE PERMIIT'W" CALL 209 953---7]699�17 FOR INSPECTIONS EX(PIIRES 1 YEAR FROM 1DATEE ISSUED <br /> • JOB ADDRESS I I Dr rc4 i n.e •\ CT'/21P� V ' ✓ J / In <br /> n r I O <br /> CROSS STREET AV-G /P'�Ny/2 Vb0 PARCELSI2E D•'l'{LgND USE APPLICATION a <br /> OWNER NAME J D O NYd fO <br /> r'�p /] PHONE P' <br /> OWNER ADDRESS / D r ribAiI Il e �'\ C /S /Z �I�I '2j <br /> CONTRACTOR W4/' r / ( Vt aT ( P Eii� C; a O d,6 <br /> G l H _ <br /> CONTRACTOR ADORE S 1 I CITY/STATE2IP S 3 01 <br /> SUBCONTRACTOR 1 PHONE •V 141 <br /> SUBCONTRACTORADDRESS ' CRY/STAT/EI2-1/rP�,Ai V N <br /> LICENSE C-57 61 D-09 Other NUMBER�UW #4 EKPINAncH DA /b C <br /> GEOGRAPHICAL NATION: Coordinates Y. Township_ Range_ Section_ <br /> INTENDED USE Oomes"'Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> udlneremlmm Owntt'. a em ame a eme°r °na um e. <br /> TYPE OF WORK New Well Replacement Well Well Alterntion/MDdifcation Other <br /> Monitoring Wells) #D/wells Soil Bonng(s) 401M""va Civitachnical sOr bO""9� <br /> Out-Of-Service Well Out-Ot-Service WFff Renewal Crass-Connection Repair <br /> New PumpPumpRe lacement Pum Re air V Raise Well Casing <br /> WELL CONSTRUCTION (t <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other �1y <br /> Proposed Well Depth R Excavation in diameter Open Bottom Gravel PaWGravel Slze in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth g `� <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 ID Dag/540 gal water) Sand Cement sack mix/7 gal water <br /> Benlonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other f1 <br /> Concrete Pedestal Dimensions:Width_fl Length it Thid in Christy Box Stove Pipe J� <br /> PUMP Submersible Turbine Other HP Pump Set it Standing Water Level f .� <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 /> MINIMUM 24 I2 AD NCE NOTICE REQUIRED FORA\II'NSP 1E�CTIIOpNS--/PLEA/lSE CALL(209)953-7697 <br /> SIGNED TmLE /�- ✓ ' Lit t/ A I oil DATE <br /> A Z O <br /> Sjpy 4 M> <br /> 'asz = mm <br /> nmq mZ <br /> CA------ —Z�-- age-i A uf ---------- <br /> N _ <br /> �z <br /> EIVED <br /> T 19 2015 <br /> DEPART T U E ONLY 'AAENTALHEALTH <br /> Application Accepted By Date �� Area �l Employee ID# g "✓IL�VICiES <br /> Grout Inspection By '.. S Well Pe"it <br /> Pump Inspection By ate WAIVER Received <br /> Sol Boring Ins ion By Date Constructed Well Depth it <br /> COMMENTS ✓ <br /> 4CC.das <br /> SC Received Chat:kAl Amount Permit, <br /> Date Info B Cash Remitted Service Request# Invoice# well 10# <br /> l o S ICa, aa�173 '5-3 2I 1 +Q©0? <br /> EHD 43Cfi <br /> 4lJO110 WELLNUMP PERMIT <br />