Laserfiche WebLink
L / PUMP PERMIT r ' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH&M!L <br /> 304 E WEBER OR°FL-STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> MwV59 rn <br /> ,J J� a �V��� `•'� <br /> JOB ADDRESS CITY/ZIP y <br /> "c" <br /> (�c l�p 1 0 <br /> CROSS STREET /F APN Z-1 0600 l PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME ((J�WC� I NG <br /> �PHONE <br /> OWNER ADDRESS � j) CITY/STATE/ZIP <br /> CZNC1\)CT1oW PHONECONTRACTOR <br /> CONTRACTOR ADDRESS y 111 1.0 y CITY/STATE/ZIPvow+ j��F�• JyfT <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSEC-57 13C-61 ❑D-09 (3Other NUMBER r EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chamcterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification Other WO—Va US <br /> 2 #of wells ❑Soil Borin s #of orings ❑Geotechnical #of borings <br /> Monitoring Well(s) g( ) <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair y <br /> WELL CONSTRUCTION ��� �/V kD +V P/I.�.t RPI--e r( <br /> Drilling Method ❑Mud Rotary )(Air Rotary ❑Auger t1 ❑Cable Tool ❑Push Point ❑Other _ <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing 3 in diameter / Conductor Casing Depth <br /> Well Casing Diameter —in <br /> Thickness/Gauge/ASTM Sched ❑Steel Plastic ❑Stainless Steel E3 Other <br /> Grout Seal De th 'Q'120 ft ❑Neat Cement(94 lb bag/S-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <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 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS CO ATION LAWS. <br /> IMU HOUR ADVANCE NOTICE REQ /�EID MFOINEC/T�IONS <br /> SIGNED TITLE <br /> DATE <br /> D 7 X 3he <br /> tA 01) <br /> 0 3 0 <br /> Af-LL—nrX AL%.LL <br /> P <br /> UN L <br /> S1 kN I �\ O <br /> E � <br /> �J DEPARTMENT USE ONLY <br /> Application Accepted By Date Q 1 �S— Area Employee ID# 3`f 73 <br /> Grout Inspection By Wdt Date D �/ d ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck#_ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By '---Cai—sh Remitted Service Request# <br /> 2 S c> q - <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />