WP0038049 - Laserfiche WebLink

Home Browse Search

4 WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-.STOCKTON CA 95205-(209)4683420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED X24- r1a JOB ADDRESS I V I7 CrrY/ZIP CROSS STREET _ppN1 r 04310EL SRE 0 LAND USE AQICATION# a OWNER NAME V A V) PHON O I v N OWNER ADDRESS ( J C,IITTY�/STATEfZIP O CONTRACTOR 0 ,((� �� I .ley! PHONE .�/�� CONTRACTOR ADDRESS \ l/ \ � ANA �i� I v W A-j� A�6)STATE21P 6P, SUBCONTRACTOR 1 'l I PHONE SUBCONTRACTOR ADDRESS CITTYY/STATEalP LICENSE C-57 L C$1 U D-09 U Other NUMBER Vl �IL EXPIRATION DATE D GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ INTENDED USE omestic/Private 7 Irrigation/Agricultural ❑Industrial 3 Water Quality Monitoring C Soil Sampling/Characterization U Public Water System If d iferent from Owner. Water tiYSterrl 1481118 Gontact Name-0—T one um er TYPE OF WORK New Well L Replacement Well U Well AlterationlModification U Other ❑MonitoringWell(s) #ofwells ❑SoilBoring(s) #ofborings ❑Geotechnical #of borings 0 Out-Of-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair U New Pump L Pump Replacement U Pump Repair u Raise Well Casing WELL CONSTRUCTION Drilling Method'rudRot ry C Air Rotary C Auger 7 Cable Tool ❑Push Point ❑ Other Proposed Well Depth2ft Excavation_l�in diameter u Open Bottom u Gravel Pack/Gravel Size in diameter rl Conduc or Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_,in Thickness/Gauge/ASTM Sched rt Steel n Plastic ❑Stainless Steel -1 Other Grout Seal Depth_ IV Q ft C Neat Cement(94 111 bag/5-10 gat water) ❑Sand Cement sack mixl7 gal water Bentonite(20%solids) L Other Grout Placement Me[hod 0 Pumped ❑Free Fall C Other 0 Retardant/Accelerator(name) PEDESTAL Installed By 7 Driller C Pump Contractor 7 Other 0 Concrete Pedestal❑Dimensions:Width ft Lengthft Thick in 0 Christy Box ❑Stove Plpe PUMP 0 Submersible?Turbine C Other HP Pump Set it Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COU TY RDINANCES, TATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT D A I E WITH T CA FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKE S O PE S TION LA N U HO RED FOR INSPECyTI/O hPL SE�/C�A/LL(209)95�- 697 SIGN TITLE�1 1��"�� 1-��( "1 DATE EIVED Y 0 4 101 MENTAL HEALTH IT/SERVICES s TA i EPATMENT U E NLY aC Application Accepted ByU41 At It to Area S Q 9 Employee ID# rD��u�" Grout Inspection By Date / ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth it COMMENTS l G 7 PE Be Receive Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service R uest# Invoice# Well ID# µs z 19-0 t)o g j4"(. I virob-12 'll EHD4 /3 �`5j''�b �•Lsrs3 eu On fYl�.•LWAAE— • WELL/PUMPPERMIT 430/12