Laserfiche WebLink
WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL <br /> /(209 953--7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> cn <br /> JOB ADDRESS 77'/��l✓� N� CITY21P Zvi// �� m <br /> D <br /> CROSS STREET APN "V PARCEL SIZE AND USE APPLICATION##'-�+� r� m <br /> OWNER NAME � Pe / rI/ PHONE <br /> r <br /> OWNER ADDRESS CITY/STATE/ZIP �J <br /> �r��. <br /> CONTRACTOR � ,1/ /LC PHONE <br /> 7 <br /> CONTRACTOR ADDRESS �[J CRY/STATE/ZIP L/f/%{� x' <br /> SUBCONTRACTOR L3 (.[r/d�{ yYl PHONE IV <br /> SUBCONTRACTOR ADDRESS CITY/S�TTATEtZIP / <br /> LICENSE >�C-57 ❑ C-61 ❑ D-09 11 Other NUMBER L 3`1 EXPIRATION DATEC C <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section_ <br /> INTENDED USE k.EC'bomestic/Private ❑ Irrigation/Agricultural ❑ Industrial Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Omer: ater System Name ontacl Na—me or one um r <br /> TYPE OF WORK b@111 w WeII ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical Fof borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ,)"ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Metho0 MU R.,04 y ❑ Air Rotary CI Augerr- ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Dept hf--w—it Excavation � in diameter ❑ Open Bottom >CGravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter tr3,-_ in Thickness/Gauge/ASTM Schad Zk— ❑ Steel XPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /60 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) >,sand Cement j� sack mi gal water <br /> 11 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method)CPumped I Free Fall ] Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By `Driller 7 Pump Contractor I Other <br /> L Concrete Pedestal Dimensions:Width ft Length ft Thtck in ❑ Christy Box ❑ Stave Pipe <br /> PUMP ubmersiblel I Turbine -' Other HP Pump Set It Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LA'NS, AND RULES AND REGULATIONS. l 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 /> MINI UM 4 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE /�� DATE ! <br /> ill's I <br /> J <br /> H <br /> ZW <br /> Q <br /> DEPARTMENT USE qNLY <br /> Application Accepted By Date 1loArea Employee Off. fi <br /> Grout Inspection By Date ❑ SPECIALWell Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection¢y Date Constructed Well Depth _. ft <br /> COMMENTS - --Zb�-- <br /> PE Sc Received Check#/ Amount Date Permit' Invoice# Well ID# <br /> Codes Info B Cash Remitted Service <br /> Request# <br /> 1578 190 3 6 3K °0 s2os7 <br /> 3g 0 SO 3 Co S¢ao->S <br /> EHD 6306 WELL/PUMP PERMIT <br /> d/3N12 <br />