Laserfiche WebLink
s WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT L;ALL (ZU9) 9bJ-tb9f FOR INSPECTIONS hAF IHh5 1 YEAR FROM !)ATE ISSUED <br />a <br />P-7 <br />JOB ADDRESS� �/�� � y f �� 7 7 �` � 7� CITY/ZI <br />F� /G <br />CROSS STRJ�YdJi-f5E APN / ` jUC PARCEL SIZLAND USE APPLICATION # <br />OWNER NAME C 7w----,- le S' ' .4 vA os. A n c2 C° .� !':21p j PHONE <br />OWNER ADDRESS _� R_ S "/ Y ? 6Y �.' <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />CITY/STATEKIP Al �7 <br />PHONE— O f%— 1`'/' T 227 <br />CITY/STATE/ZIPl <br />PHO <br />SUBCONTRACTOR ADDRESS/ CITY/STA <br />/TE <br />//ZIP <br />LICENSE C-57 C-61 D-09 Other /7 + NUMBER (ca 0666 EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural J Industrial Water Quality Monitoring Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name-------- C—ontact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Mod ificationOther APIV <br />❑ Monitoring Well(s) # of wells 1iSoil Boring(s) p or borings ❑ I a of borings <br />7 -Out -Of -Service Well L-1Out-Of-Service Well Renewal Cross epai <br />New Pump Pump Replacement Pump Repair Raise f <br />xvt-1 <br />WELL CONSTRUCTION (K-Itb <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth__ _ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ElSteel ❑ Plastic I Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped ❑ Free Fall Other i Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal []Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible i 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE ® +— 'DATE <br />A lication Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />T 2l1 E N T LIC E N L Y <br />Date — <br />Date <br />Date <br />T <br />.H <br />D <br />v <br />v <br />rn <br />rn <br />Area Employee 047-4.1 ' r'w "" <br />1 SPECIAL Well Permit <br />I WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS l� <br />PE <br />Sc <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted , <br />Date <br />Permit/Codes <br />Service Request # <br />Invoice # Well. ID# <br />i rl >" <br />o -JL, I I <br />P-,uc i cmc Z <br />EHD 43-06 WELL /PUMP PERMIT <br />hk�i30112 <br />