Laserfiche WebLink
WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH', ARTMENT 304 E WEBn 3R°FL-STOCKTON CA 95202 - (209)468-3420 1 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YjaRh <br /> JOB ADDRESS I '7 S 1V t e- jet CITY/ZIP t <br /> CROSS STREET w` APN� ae;) -gy �[� � �j Q <br /> --, ARCEL SIZE LAND USE APPLICATIO/N.# S <br /> OWNER NAME „ � PHON <br /> OWNER ADDRESS �� ,�Lkl CITY/STATE/ZIP fx. { <br /> r <br /> CONTRACTOR �� % $ /`� JPPHHON I y <br /> CONTRACTOR ADDRESS I f CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISSTATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER QCT EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USEDomestic/Private (3Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring E3 Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: ater ystem ame Contact Name or Phone Number <br /> TYPE OF WORK Aew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(s) aofbO°°p ❑Geotechnical a of borings <br /> 0 Out-Of-Service Well ❑put-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pume Repair <br /> WELL CONSTRUCTION <br /> Drilling Method>CMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point 0 Other <br /> Proposed Well Depth f�( `�ft Excavation 7_ in diameter ❑Open Bottom ravel Pack 1 Gravel Size in diameter _C) <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameterin Thickness/Gauge/ASTM Sched /1K e?_ ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ZA!20 _ft ❑Neat Cement(941b bag/5-10gal water) ❑Sand Cement sack mix 17 gal water —�J <br /> gBentonite(200/.solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method meed ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Wump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions;Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> n <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORT{ WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE ISy <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 01 <br /> l MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / y�g �ry <br /> SIGNED l`(�', t`� � TITLE h1//�f� DATE /���4� <br /> I <br /> Ir <br /> I <br /> IF <br /> Iry <br /> l� <br /> 2 L <br /> i <br /> 4 7 <br /> _ � 1 <br /> r: ( 1 � A d A A <br /> A <br /> DEPARTMENT US�E4ONLY <br /> Application Accepted By `yy Date 5 0S Area s <br /> �C �_� EmployeeID# C, 10 <br /> Grout Inspection By Irl (r Date ) d ❑ SPECIAL Well Permit <br /> Pump Inspection By ✓ Date 1 ❑ WAIVER Received <br /> Constructed Well Depth ft 1' <br /> COMMENTS �`uC-C3��✓� <br /> PE SC Received Chec Amount Permit/ <br /> Codes Info Cash Remitted Date Service Request# Invoice# Well ID# <br /> •4�.IiL tdz D �3� .t.2? 1�17�� t� 3 <br /> 99i <br /> EHD 43-02-006 <br /> 18712005 <br /> WELL PUMP PERMIT <br />