Laserfiche WebLink
Iv^\-_�a%�5 Wit^ Vj-_51 116 1)L".^ <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,p� CITY/ZIP `d C !✓a �2/ o <br /> CROSS STREET i9 -l� APN:z / —=—O PARCEL SIZE LAND USE APPLICATION# <br /> � / m <br /> OWNER NAME T! S 6I,� PHONE C�zl�d d 0 !--< y <br /> OWNER ADDRESS � CITY/STATE/ZIP <br /> CONTRACTOR ��j�YJ p�L- �f PHONE 3-5 3;1— 72_ <br /> CONTRACTOR ADDRESS ♦'-� CITY/STATE/ZIPC.- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS _ CITY/STATT?E/ZIP <br /> LICENSE /C-57 C-61 D-09 Other NUMBERS,77 3iD-r EXPIRATION DATE 7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Li Domestic/Private _ Irrigation/Agricultural a Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water —stem Contact Name or Phone Number <br /> TYPE OF WORK 1<New Well IReplacement Well ❑ Well Alteration/Modification Other <br /> ii Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical_ #of borings <br /> _1 Out-Of-Service Well 11 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> w Pump Pump Replacement ❑ Pump Repair IJ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method`Mud Rotary Air Rotary Auger r-1 Cable Tool Push Point P Other <br /> Proposed Well Depth3.__2 ft Excavation j.s in diameter Open Bottom ravel Pack/Gravel Size in diameter <br /> Conducr Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamete �inn/�Thickness/Gauge/ASTM Sched 2 � Steel >01astic 11 Stainless Steel ii Other <br /> Grout Seal Depth�7 C—ft% Neat Cement(94 Ib bag/5-10 gal water) Sand Cement- A-. sack mix/7 gal water <br /> Bentonite(20%solids) 1 Other <br /> Grout Placement Method-<Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By_X Driller Pump Contractor Other <br /> - > <br /> Concrete Pedestal Dimensions:Width _ft Length ft Thick in Christy Box Stove Pipe <br /> I PUMP .'<$ubmersible Turbine 1 Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAI' 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 /> MINIMPM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)9.53-7697 <br /> SIGNED � �,� i — TITLE V�✓/ ice DATE <br /> 1✓V/ j14 <br /> !tc <br /> nr <br /> n <br /> ,DEFJARTMENT USE 9NLY <br /> 3/ 20 <br /> Application Accepted Date Area-40 Employee ID# <br /> Grout Inspection By. Date fi L1SPECIAL Well Permit �� <br /> Pump Inspection By Date 64 L1 WAIVER Received <br /> S()i'Boring Inspection By Date Constructed Vyell D thft <br /> COMM EN FS <br /> PE SC Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 3�1 `� �� > <br /> HE)13-06 WELL/PUMP PERMIT <br /> h6h X30/12 <br />