Laserfiche WebLink
E. <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />.O <br />I GO`o <br />CIT/ZIP 9S5-7-1 <br />`.1 <br />CROSS STREET <br />T <br />� O <br />APN ^LO - '110 3 1 PARCEL <br />SIZE '40#46 LAND USE APPLICATION# <br />OWNER NAME M\)1Sco <br />FQIY\t1V <br />011VC C-0• <br />PHONE <br />OWNERADDRESS ,-j-{5ON.W0-W0O\o"• <br />-11 <br />CITY/STATE/ZIP 'Tro-q)� vP`% Ili S1J6 <br />CONTRACTOR H C ' <br />6ro5. Dr;iX;n <br />nC. <br />PHONE4'5 l U <br />Do <br />CONTRACTOR ADDRESS <br />96A r.."\ <br />• <br />CITY/STATE/ZIP moa C-5+0 ch 91 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATEIZIP <br />C-61 I D-09 <br />Other NUMBER ;L90'61 EXPIRATION DATE S —3 1 — 1 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE E Domestic/PrivateIrrigation/Agricultural I Industrial Water Quality Monitoring I Soil Sampling/Characterization <br />i_i Public Water % m <br />If different from Owner: Water Svstem Name on ac ame or one um r <br />TYPE OF WORK r( New Well Replacement Well E Well Alteration/Modification 'i. Other <br />Monitoring Wells) # of wells D Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well E Out -Of -Service Well Renewal i Cross -Connection Repair <br />New Pump Pump Replacement I I Pump Repair i Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method )(Mud Rotary Air Rotary Auger Cable Tool Push Point 1 Other <br />Proposed Well Depth 50ft Excavation - 118— in diameter Open Bottom Gravel Pack/Gravel Size in qIameter <br />Conductor Casing in diameter / Conductor Casing Depth ft BICnd <br />Well Casing Diameter_Min Thickness/Gauge/ASTM SchedSO R.2-1 1 Steel Plastic Stainless Steel Other <br />Grout Seal De thSMft I Neat Cement (941b bag/5-10 gal water) / Sand Cement sack mix/7 gal water <br />Zenton to 20% solids) G Other <br />Grout Placement Method umped -i Free Fall Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By I i Driller ump Contractor i 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 />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 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 />DEPARTMENT USE ONLY <br />Application Accepted By 'f -9 �'P"`�'^'Date ( I� Area � � 41Employee ID#_�G <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection B Date Constructed Well Depth ft <br />COMMENTS til/- i!' 4LT <br />EH043-06 WELL/PUMP PERMIT <br />8/04/08 <br />