Laserfiche WebLink
EHD 43-02406 <br />107/2b05 WELL PUMP PERMIT <br />WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Ave 3e1' FL - STOCKTON CA 95202 - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL (209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />W. . <br />A0...„...X---765- JOB ADDRESS (4, I 0-2-) TD42 X A-C1, -A--e- crnizip-TT-0,-1 5 <br />CROSS STREET 4-1.r (-).. 3 APN p 1 3) 0a:22/PARCEL SIZE Y6- q 5 30 ,-1 <br />(C:7 LAND USE A PLICATION # <br />OWNER NAME ‘. -0-1. \ *4-F. kni-Ac-, PHON P`i.) ‘ - -5 1 <br />OWNER ADDRESS ‘ko \i ec\ -GnA- \J'Nk , ciTy/sTATvzipl\nc-6e ji:: CA <br />CONTRACTOR Ale I rri9c,...-*-0r1 , <br />CONTRACTOR ADDRESS 2-15 W ---4.-- ciTysTATEizip A--)......:cov, C,y\-..1.5"..7,1,40 ...0.-.1r-, <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEiZIP <br />LICENSE 0 C-57 0 C-61 0 D-09 XOther C -\\--,,i NUMBERLcko-2...72.... EXPIRATION DATE (- AD <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED OSE y(DOMCSBC/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling /Characterization <br />0 Public Water System <br />If efferent from Owner, Water System Name Contact Name or Phone Number <br />TYPE OP WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) if of wells 0 Soil Boring(s) a of 6onngs 0 Geotechnical it of borings <br />0 Out-Of-Service W II 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump Pump Replacement 0 Pump Repair <br />WELL CONSTRUCTION i <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth 11 Excavation in diameter 0 Open Bottom 0 Gravel Pack / Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag/ 5-10 gal water) 0 Sand Cement sack mix I 7 gal water <br />0 Bentonite (20% solids) 0 Manufacturer Spec % solids % Name 0 Specs on File 0 Specs Submitted <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PFDES1'AL Installed By 0 Driller 0 Pump Contractor 0 Other I <br />0 Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP XSubmersible 0 Turbine 0 Other HP 7— Pump Set el ft Standing Water Level I 5 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> TITL —e/-7 /77/7- DATE <br />C IL" <br />;) 07 <br />JAN ti 0 9-0 7 <br />ENVIRO AENT HEALIt- <br />FERM, ifL-F VICES <br />3/4'. t GoLP <br />-ND,* tolF!•-,1. <br />S;44-4‘' <br />F61 <br />ke4=1.9 <br />L <br />f <br />le <br />c=1 <br /> <br />EPA ME SE ONLY <br />Application Accepted By )-af <br />D NT <br /> <br />X)-7L <br />ate / Area Employee 1130 if° YrShy <br />Grout Inspection By oDate 0 SPECIAL Well Permit <br />Pump Inspection B .&;1W%le...te 0 WAIVER Received <br />Constructed Well Depth <br />COMMENTS Sit.W-702- 7-4e3 L/4/-4/2:-,7 e.;-- 4'.e/Cs <br />4z4_, <br />PE <br />Codes <br />SC <br />Info By <br />Received .L--Cleast_c / ) Amount <br />Remitted Date Permit/ <br />Service Request 0 Invoice # Well Ma <br />10 -1.) G— \ \ b 1 :5-6 \1,301,D1 <br />rti <br />ft