Laserfiche WebLink
14v o <br /> WELL/PUMP PERMIT -3/9M <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 1 YEAR FROM DATE ISSUED <br /> 5?2y gw6Da � pp � Q <br /> JOB ADDRESS r� CITY/ZIP Wnt `'SZy Z- D <br /> _ ytUr,Jj O <br /> CROSS STREET I Ko,c-�,'OIIJ Y' APN v 55-1`t(9-l2 PARCEL SIZE Z _LAND USE APPLICATION# �q1 <br /> OWNER NAME �c�.1G C�IA0 Y PHON-TtE�� <br /> OWNER ADDRESS Y So(.` 3' 14T -'W AF o), C-L}LI��_' CIIT`Y/STA-TE�/ZJIPL.� L--N)I <br /> CONTRACTOR L �Vt CICJOUL-� 6rTl7S,�L. U u"�c�c..aC•w U M'y�`^'1 PHONE . 131�0�.7- 37x1 <br /> CONTRACTOR ADDRESS 9vi �w�lu S't Ix-1 KFL Wim'-( CITYISTATEMIP <br /> SUBCONTRACTOR PHONE_ <br /> SUBCONTRACTOR ADDRESS _ _ CITY/STATE/LP <br /> L.rC <br /> Q(,2`!DOT ExPIRATION DATE <br /> , ENBE �CSC-611C-6117 GD-09Other NUMBERI <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> gRENDED USE Domestic/Private Inigation/Agricultural Industrial Water Quality Monitoring KSoil Sampling/Characterization <br /> Public Water System <br /> I!affe'ent from Owner _ Water ys em ansa on ansa or a um <br /> TYPE OF WORK New Well Replacement Well Well AlteratiorvModfication Other <br /> Y of borings #'of boring' <br /> Monitoring Well(s)_____#of wells - Soil Borings) Geotechnical <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump -Purim Re acement U PUmp Repair ___ Raise Well Casing <br /> W_E_UL CONSTRUCTION <br /> Drllliig Method XMud Rotary Air Rotary Vikuger Cable Tod Push Point Other <br /> Proposed Well Depth 15' '50 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__ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth_ it )C-.Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other `�1L C-y'(�IaX-r X11 brv�"ts+��<- CkAin \F uJ'Ac. '4L <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> Ivry Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width R L Ick in Christy Box Stove Pipe <br /> IPs� Submerslbie Turbine 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 /> lH- <br /> MINIMjt 24 TADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASECALL(209)953-7697 <br /> SIGNED , <br /> ( r TITLE � �'V <br /> VAT' <br /> --' -T <br /> J^ <br /> F. <br /> n DEPARTMENT USE ONLY /- C �( <br /> Application Accepted By - �� /e"'� Date t i Area ��4 C1'"' Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection Dale ❑ WAIVER Received <br /> Soil Boring Inspection By Date �l✓ JT Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Recelvad Amount Date- --_ PennlV -__ Invoice# Well IDX <br /> Codes Into B _Cash Remitted Service Reauest# <br /> EHD43-084 WELL RUMP PERMIT <br /> 4W12 <br />