Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA95205 - (2O9) 468-3420 <br />nuavicEFVNDAst_Ellr/E�RMrT t I:ALL LUy V34-1 111 FOR INSPECTIONS k:ArIKES 7 YEAR FROM VATE ISSUED <br />JOB ADDRESS L jj� \ ((�[ �J D `y a CITY17jP -T( [ \( CA <br />r v <br />CROSS STREET APN PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME �A M O A x b S(�� 6 C'3 PHON, � X�7 <br />l� <br />OWNER ADDRESS �7� 5 r O�X�a \�� `i (� CITYISTATEOP ( 0' r <br />CONTRACTOR C �C) 71- it C • PHONE (C\ ci nk -E <br />-k\,� �t1a o <br />CONTRACTOR ADDRESS JY ()rU C5 ('QYL �� CmrISTATEOP Lt�C acnef�1t OT A 9 <br />TOR ADDRESS <br />ENSE ❑ C-57 X-61 17 D-09 ❑ Other <br />PHONE <br />��yCITY/STATE/ZIP <br />V <br />NUMBER b 3to \\,e EXPIRATION DATE <br />V <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE ❑ Domestic/Private ❑ IrrigationlAgricultural O Industrial ❑ Water Quality Monitoring ❑ Soil Sam pli nglCh aracterizabon <br />❑ Public Water System <br />Ifdifferent from 0wner: water System Name contact Nameor Phone NUMber <br />TYPE OF WORK t7 New Well ❑ Replacement Well ❑ Well Afters tion(Modification ,'@40ther t I - S 0,��\ � Qrah r 5 <br />O Monitoring Weli(s) # of wells ❑ Soil Bodng(s) "' """""' ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewed ❑ Cross -Connection Repair <br />❑ NewPumD ❑ PumD Replacement ❑ PumD Repair ❑ Raise Well Casina <br />Drilling Method ❑ Mud Rotary D Air Rotary ❑ Auger D Cable Tool 0 Push Point * Other QV C- V <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PackJGravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter I in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag(5-10 gal water) 0 Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />o Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box o Stove Pipe <br />o SubmersibleD Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THS 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 />c <br />DEPARTMENT USE ONLY <br />Application Accepted By (�� <br />Date <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />srn <br />bn <br />b <br />v <br />a <br />M <br />N <br />ERi <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#t Amount <br />Cash Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />Cun I'J nF H a6tpC C6� -X00 <br />0 / X1&07 ,nrcl I rod 1,40 0.0M IT <br />