Laserfiche WebLink
+ WELUPUMP PERMIT �� <br /> SAN JOAQUIN 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'I YEAR FROM DATE ISSUED <br /> r ' ex ronV C4 <br /> �U1�r� Ca g53Zo m <br /> JOB ADDRESS CITY/ZIP D <br /> CROSS STREET r V APN `' '?5w)J PARCEL �z LAND U APPLICATION= m <br /> II (JC UUS� <br /> OWNERNAME `J� 1G�.1' G �r MILh '/��la HONE <br /> OWNER ADDRESS V v[ Q�I b ) yy� CITY/STATE r lop �� <br /> CONTRACTOR • 7vi) V L// L //� 1 PHONE <br /> CONTRACTOR ADDRESS 0 61 ✓�'V l u rt CITYCITY/�� ✓V C rj �� l <br /> SUBCONTRACTOR &R r ' PHONE <br /> SUBCONTRACTOR ADDR�ESSS1 IV rrY/STATE/ZIP v, <br /> LICENSE % C-57 V C-61 0-09 Othe NUMBER I " `^ EXPIRATION DATE 1 =x�I' <br /> GEOGRAPHICAL INF TION: Coordinates X Y Township_ Range Section_ <br /> INTENDED UsE Domesti jPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: water ys err Name contaCt Name or Frone Number <br /> TYPE OF WORK New Well Replacement Well Well AlterationlModification Other <br /> Monitoring Wells) #of wells Soil Boring(s) a of borings Geotechnical #of borrj <br /> Out-Of-Service WyM Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump VPumpReplacement_ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other 1 <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other p <br /> Grout Seal Depth It Neat Cement(94 Ib bag15-10 gal water) Sand Cement 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 Len th ft Thick in Christy Box S!!APIpe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN t) <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS —V <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL �f <br /> WORKERS COMPENSATION LAW . <br /> MINIMUM 24 HO DVANCE NOTICE REQUIRED FO NQSPECTIONSyy-PLEASE CALL(209)9F53-769/ <br /> U11 I 7) 1 N <br /> SIGNED TITLE ` �� ATE �I D / O <br /> 84 y4f, <br /> JAN 0 82018 <br /> NV/RC)H�N COIJN <br /> Ty DEPgR�eN�Y <br /> VED <br /> N o 8 201? <br /> 1TIS <br /> SETARO,L R ALTH <br /> CES <br /> A, _R ME <br /> NTT ISE JOY <br /> Application Accepted By e Area Employee ID# b <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By tUCk') LAWNDate WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck#/ Amount Permitl Invoice# Well ID# <br /> Cods Info B Cash emitted Date Service Request# <br />