Laserfiche WebLink
C / i <br />WELL/PUMP PERMIT <br />SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON! -REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOF3 ADDRESS 343 W ANDERSON ST CITY/ZIP Stockton / 95207 <br />VAN BUREN ST APN 147-102-09 (In front of) 7461 acres <br />CROSS STREET �_._.�.p, PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME PG&E�YTTTT t(1 1 1 ! J-" PHONE 209-942-1421 <br />OWNER ADDRESS 4040 West Ln CITY/STATE/ZIP Stockton / CA / 95204 <br />CONTRACTOR PG&E PHONE <br />CONTRACTOR ADDRESS 535 S Center St CITY/STATE/ZIP Stockton / CA / 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE ■ C-57 <br />C-61 <br />D-09 <br />CITY/STATE/ZIP 7 <br />Other NUMBER 339629 EXPIRATION DATE <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 uontacl Name or F ne um er <br />rvoc r1c 1Almov E M.— lAloll M. Wcll 1Alc11 Alt—finnIRAM ifinnt inn ■ r)thnr Anode Well <br />Monitoring Well(s) # of wells <br />Out -0f -Service Well <br />SoilBoring(s) #of borings Geotechnical <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />Pump Repair Raise Well Casing <br /># of borings <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 200 ft Excavation $� in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched Steel ■ Plastic Stainless Steel Other <br />Grout Seal Depth 100 it Neat Cement (94 Ib bag/5-10 gal water) ■ Sand Cement 10.3 sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method ■ Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine ■ Other N A HP Pump Set ft Standing Water Level It <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIIAUM=VANCE <br />4NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ( TITLE Associate Distribution Engineer DATE 1-- 'Nis ii l <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring In pection By <br />COMMENTS r <br />z <Vrn ��4� <br />L 4q bV Cj A �"V, <br />z Q <br />�DW <br />W ANDERSON ST <br />JP RTMENT U$iE ONJ�Y <br />Date (Jf� <br />ate <br />Date tt <br />Date d <br />Area I / 5� vnEmployee ID# t.JU <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received Check#/ Amount <br />Info B Cash Remitted <br />Date <br />Permit! <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-06 WELL !PUMP PERMIT <br />4/30/12 <br />