Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> `i (� n yrs {��' C—�``^�, `v��,•F y <br /> .. JOBADDRESS // S t9 X16'+-/`i..SW, ' � L' CITYIZIP <br /> CROSS STREET f /�)/ A�7P''NN t SII 3 7 PARCEL SQE�'S LAND USE <br /> AAPPLIICCCATION.# ,1 <br /> P? <br /> OWNER NAME M'1�A/Q/� C.� i2t PHONE I,/ ` v S 2y y <br /> OWNER ADDRESSrys�C j- CIN/STATEZP <br /> • <br /> CONTRACTOR F ss peel& PNO�NE f> ` t1�`5 <br /> I CONTRACTOR ADDRESS A y/=/�lL,7 , 1-7 CI7YISTATE21P G��jV F�ILJ�CE <br /> k SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CATY/STATE21P <br /> LICENSE ><C-57 O C-61 n 0-09 D Other NUMBER <T6WS EXPIRATION DATE C-111 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ,[DomestidPnvate 0 irrigation/Agricultural n Industrial 6 Water Quality Monitoring n Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water by3Zem ame ,att NaM4 or PWne NUMDer <br /> TYPE OF WORK leW Well D Replacement Well D Well Alteration/Modificallon 0 Other <br /> p <br /> . D Monitoring Wells) #of wells D Soil Boringof borings ❑ <br /> s) Geotechnical of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑CrOSS-Connection Repair <br /> ;�Slew Pump ❑Pump Replacement D Pump Repair D Raise Well Casing <br /> I <br /> WELL CONSTRUCTION -- <br /> jDrilling Method_.Cud Rotary ❑Air Rotary ❑Auger D Cable Tool ❑Push Point ❑ Other _ <br /> Proposed Well Depth Z_60 It Excavation 2—in diameter D Open Bottom Gravel Pack/Gravel Size in diameter <br /> O Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter 4 in Thickness/Gauge/ASTM Sched 7-21=1 ❑Steel Xc:Vlastic D Stainless Steel D Other <br /> Grout Seal Depth 12,,O ft ❑Neat Cement(94 lb bag/5-10 gal Wafer) >i-Sand Cement ��% sack mW7 gal water <br /> O Bentonite(20%solids) n Other <br /> Grout Placement Methodv�Pumped D Free Fall D Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller D Pump Contractor D Other <br /> D Concrete Pedestal Dimensions:Width ft Length ft Thick <br /> in ❑Christy Box ❑Stove Pipe <br /> I PUMP ;l-Submersible❑Turbine D Other HP Pump Set ft Standing(Nater Level ft <br /> ( I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> II 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 /> M4 HtaUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209`)953-7697 <br /> SIGNED �iLtT- TITLE �C.p-�Lt�� DATE`���t-11) <br /> f <br /> rl I <br /> l <br /> Ri <br /> I <br /> IAYMfl <br /> � I III I 6 <br /> I i <br /> IJbAdiwAc YA <br /> I I E ASM <br /> L I <br /> r <br /> A R T M E N T USE ONLY <br /> Application Accepted y ate 00 <br /> f(`22—jc Area 1 Employee ID#s9�y <br /> Grout Inspection By Date O ❑ SPECIAL Well Permit <br /> Pump Inspection Date / Fl WAIVER Received J <br /> Soil Boring Inspection_By Dbte Constructed Well Depth It <br /> NTS Q <br /> I PE SC Received Check#/ Amoun Permit/ <br /> Codes Info B ash Remitted Date Service Re uest# Invoice# WellID# <br /> I <br /> �0U !o I <br /> EHD 43-0e �74a�iyllSS�i!c 5 j PESE�MF�C C� <br /> srzaro9 <br />