Laserfiche WebLink
i336'� (c 1 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1866 East Hazelton Avenue-STOCKTON CA 95205.6232 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECT19 S EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I�.iN LC�E'r IA[ ILII Irl D —y-� CITY/ZIP VTJ C1C\r� rl ['L�10 m <br /> CROSS STREET LJG9ij-bre U APN (JStAJT. (W")PARCEL SIZEW1 & LAND USE APPLICATION#�� <br /> OWNER NAME _ PHONE -11 (meq Il <br /> OWNERADDRESS 1210 V G /�-�-I-b ✓1 lg:h /��� CITY/STATE/ZIP <br /> CONTRACTOR `g �,..40-A`(,i YC'� l t'} A I"Ji& /7,76 <br /> CONTRACTOR ADDRESS `911 I �-�� �-���•ly`�l ��:fl-I M CITY/STATEIZIP�5�` ,IC+--in�����CIL <br /> SUBCONTRACTOR 1/ �.) �'�\ `�✓L=1 PHONE 20�-j <br /> SUBCONTRACTOR ADDRESS A"O "�`f I tj�a � � tIK> CITY/STATE/ZIP <br /> ILICENSE C-57 C-61 D-09 Other NUMBER - Ina n %- EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> 1t7TENDED USE Domestic/Pnvate IrrigationiAgricultural Industrial Water Quality Monitoring Ksoil Sampling/Characterization <br /> Public Water System <br /> If dMerent from On, Water Ziy5temi Name on ac me or Phone Numb., <br /> I _ <br /> TYPE OF WORK New Well Replacement Well Well Afteration/Modification Other <br /> R <br /> Monitoring WellgM of bonngs of boringes) #of wells Soil Boring(s)s) Geotechnical�_ <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> _ New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> j Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 10 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bagIS-10 gal wafer) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) OQQther CQj X ;,.]L4,yj- <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It 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 /> `-AlINIMIJ 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED <br /> J. - TITLE �n)Q-C 1 C-�1C 11 ice`-"_r DATE <br /> Ut NTY <br /> L <br /> N I1 ENT <br /> E l- <br /> rid 4flK I r <br /> DEPARTMENT USE O N L Y <br /> Date _ area�_t.__. Employee ID# <br /> Application Accepted 8y i <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection Date / WAIVER Received <br /> Sod Boring Inspection By Date �< ��� Constructed Well Depth ri <br /> COMMENTS <br /> -illi ` <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B `-Cash Remitted Service Request# <br /> ��- iso C 1353 3 `f 3ti "RcxQ0 70 . <br /> WELL/PUMP PERMrr <br /> EH7 43-W <br /> 8.0418 <br />