Laserfiche WebLink
O= 3!a art,, WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZEL.TON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED in <br /> JOB ADDRESS �`/1�/C Lf �\�� CITY/ZIP��� _ m <br /> AICROSS STREET lY'/�JLNN APN_�5}' _Ie4l-C7S s/ o <br /> n y�J PARCEL SIZE .AND USE APPLICATION# m <br /> cn <br /> OWNER NAME PHONE— �— <br /> OWNER ADDRESS �' /����JJ/�- / CI-fY/�rS,TlATE21P <br /> CONTRACTOR � /f�iI��OS � 2 ' /IL PHONE / 3/ &zzl) <br /> CONTRACTOR ADDRESS ��/�C ' ��L C� ��' ,fes'�/ CITY/STATE/ZIP <br /> J ] iS <br /> SUBCONTRACTOR PHONE— <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ZC-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township__ Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural ❑ Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> U Public Water System_ <br /> If different from Owner: Water ystem Name Contact Name or Phone Number____ <br /> TYPE OF WORK/, New Well Replacement Well El Well Alteration/Modification Other <br /> ❑_Monitoring Wells __— _7 Soil Boring(s)#of wells ' S #of borings #of borings <br /> - gO _ Geotechnical <br /> I Out-Of-Service Well ❑ Out-Of-Service Well Renewal a Cross-Connection Repair <br /> ew Pump it Pump Replacement n Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool Push Point I Other <br /> Proposed Well Depth_ Lr ft Excavation �Z _ in diameter I Open Bottom }ravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth / ft <br /> Well Casing Diameter_4(,�_ in Thickness/Gauge/ASTM Sched _.��� ❑ Steel :Blastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 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 ICYump Contractor Other <br /> Concrete Pedestal Dimensions:Width:&-ft Length ft Thick in Christy Box StovVi <br /> e Pipe <br /> PUMP submersible Turbine Other HP Pump Set ega7 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 /> MINIM R =NOTICE REQUIRED FOR INS ECTIONS- PLEASE CALL (209)953,-77 <br /> SIGNED � 1 —�, TITLE_ ! /�caE ` DATE <br /> c - / <br /> 9 <br /> 'd <br /> 1.L. <br /> YL \ <br /> 1 <br /> � .� . <br /> r <br /> y <br /> S N <br /> c <br /> EPARTMENT USE ONLY Uf'p�N;AC TY <br /> � MINT <br /> Application Accepted B Date Area Employee ID# Lr <br /> Grout Inspection By � Date / - 1 SPECIAL Weil Permit <br /> Pump Inspection By \ °>l1VY\ DateI WAIVER Received <br /> Soil Boring Inspection BY _ Date 1 �Q Constructed Well Depth . ft <br /> COMMENTS <br /> ) <br /> PE SC Receivedeckg Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> C? SC? gS /S S(2.0 6.-7 5 <br /> O <br /> EHD 43-06� /�-j, WELL/PUMP PERMIT <br /> 4/30/12 <br />