Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE <br />PERMIT <br />,, j .... w CALL (209) (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 'N1 /��Z CITYMP <br />CROSS STREET_ _� TLS St" A P N 0 1 I�I 06 1PARCEL SIZE 30 LAND USE APPLICATION N <br />OYfNER NAMElP,HONED`-l�"� <br />OWNER ADDRESS t%/�/v� �'�Y,(T' �� � �C ' CQ%D �t CRY/STATEIIJP <br />CONTRACTORyyrLL . PHONE iqIj(( 3�Q <br />Q(CA <br />.SUBCONTRACTOR <br />CONTRACTOR AODRES$gqT���`�` � C� CITY/STATE21P ( <br />C. O l.�'>r�JCtTT L �/A <br />.SUBCONTRACTOR lS _\(ASrrt PHONE (/U \ K \ � &b <br />SUBCONTRACTOR ADDRESS %v` _V`�'J_-7CITY/STATEZP_ <br />LICENSE 7LL-57 C£1 D-09 Other NUMBER(_ EXPIRARON DATE <br />GEOGRAPt4CAL INFORMATION: Coordinates X SR -.R— I/�/ C Y Township_ Range Section_ <br />INTENDED USE Domes%UPrivate Imgation/Agncullural Industr al Water Quality Monitoring Soil SamplingfCharactenzatlon <br />Public Water System <br />if elrferant ham Owner wafn ys em ame c ame or ne u er <br />TYPE OF WORK New Well Replacement Well Well Alteration/Mad'Ificahon )&ther $'� J <br />MonitoringWell(e) #of wells Soil Boring (s) x°I N° Geotechnical eerbonnps <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary 7L/tuger Cable Tool Push Point Other <br />Proposed Well Depth �y{1 It Excavation E(/ in diameter Open Bottom Gravel PackJGravel Size in iameter <br />Conductor Casing in diameter / Conduct Casing Depth ft <br />Well Casing Diameter 2n Thickne���s,,,s//111Gauge/ASTM Sched _ Steel laelic Stainless Steel Other <br />Grout Seal Depth k 10eat Cement (94 /b bag/S10 gal water) Sand Cement sack mi gal water <br />Bentonite (20% solids) / _Other <br />Grout Placement Method Pumped \/4ee Fall Other Retardant / Accelerator (name) _ <br />Installed By )00611er Pump Contractor Other <br />Concrete PlIndestal Dimensions Width ft Length ft Thick in <br />Pipe <br />PUMP Submersible Turbine Other HP Pump Set If 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. 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 2 V NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7'97 <br />SIGNED TITLE DATE <br />EC <br />Application Accepted By <br />Grout Inspect on By <br />Pump Inspection By <br />Soil Bonng Inspection By <br />COMMENTS <br />T M E N T U N Y <br />Date <br />Date <br />Date <br />Date _ <br />i <br />Area` moloyeeIU#•�� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth K <br />PE <br />Codes <br />SC Received Chedd4 Amount Date Permit/ Invoice k Weil ]DO <br />Info Cash Remitted Request # <br />�SService <br />(A) f r'P� ✓ <br />EHO 43*6 <br />V33/'.2 <br />c!w -#OSo X36 <br />WELL IPUMP PERMIT <br />