Laserfiche WebLink
�, WELL/PUMP PERMIT' <br /> SAN JnAQUA COUNTY ENVIRONMENTAL HEALTH DEPA T Ep 1868 EAST HAZELTON AVENUE- 3TOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT JAZ -5- LL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LD <br /> JOB ADDRESS fi CITY/ZIP /SIT J 33� <br /> h / L i <br /> C D <br /> CROSS STREET J. I�y�i an APN PARCEL SIZE.LAND USE APPLICATION# o <br /> OWNER NAME G-,ckv)c- ( L'Njo LJ' w'w -q PHONE u <br /> OWNER ADDRESS yn 6(7'%6 l0CITY/STATE/ZIP /� L,a C_ _A 6c <br /> CONTRACTOR A �'�� I ( , - �' PHONIC��p j ~�Tr�- t ZL{ <br /> I f -- -A <br /> CONTRACTOR ADDRES <br /> (.I I CITY/STATE/ZIP-5 tL <br /> `/ <br /> SUBCONTRACTOR �r &4j W 1 ► PHONE(� <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP ,!CCC ISGSZ <br /> LICENSE �=-57 H C-61 11 D-09 Other NUMBER Z EXPIRATION DATE O 2D <br /> DOMESTIC WELL SAMPLING: U General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE U Domestic/Private L Irrigation/Agricultural L Industrial L Water Quality Monitoring 1t doil Sampling/Characterization <br /> L Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1 1 New Well i I Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> L Monitoring Well(s) #of wells j4.Soil Boring(s)_� #of borings L Geotechnical #of ` <br /> Li Out-Of-Service Well L Out-Of-Service Well Renewal U Cross-Connection Repair '1Y�0� <br /> i i New Pump Pump Replacement 1 Pump Repair I Raise Well Casinge � <br /> WELL CONSTRUCTION ��� <br /> Drilling Method CI Mud Rotary LI Air Rotary Auger I] Cable Tool 1 Push Point U Other o <br /> Proposed Well Depthft Excavation 6o" in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size &._Oq n diam r <br /> L Conductor Casing in diameter / Conductor Casing Depth ft HF,q�TR1R-ONM COON <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched I Steel n Plastic 0 Stainless Steel Othe rO�Pq�NTAC <br /> Grout Seal Depth s -1,5 ft q4 Neat Cement(94 Ib bag/5-10 gal water) 1i Sand Cement sack mix/7 gal w er <br /> U Bentonite(20%solids) L Other <br /> Grout Placement MethodPumpedL Erea-y- .G�ll I Other L Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller U Pump Contractor L Other <br /> N p L Concrete Pedestal UDimensions:Width ft Length ft Thick in L Christy Box U Stove Pipe <br /> PUMP A I I Submersiblell Turbine El Other HP 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 /> M:11, U S HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE ktQ P9�O 1 S ` DATE I <br /> Tj <br /> RTMENT U E P9 L V <br /> Application,Accepted By Dai Arca 6Lmployeo ID h1*&h <br /> b!� <br /> Grout Inspection By Date L SPECIAL W(MI Pa:V'u'9'lit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By�'�41 V-A�-� Date Constructed Well Delrth <br /> COMMENTS <br /> PE SC, Received Lwcc ' Amount Permit/ Invoice 1`• Well <br /> Codes Info Bif ash G emieaed Date Service Requests <br /> tOD;v <br /> C, �J3o1►���� <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 3/04/08 <br />