Laserfiche WebLink
WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT `,CALL(209)953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS / %� VT CITY/ZIP y �]��r IG /�/ ��/, Z 9 <br /> CROSS STREET W 1 PAAl- T APN � Z `P Z--PARCEL SIZE —71 LAND USE APPLICATION# <br /> OWNER NAME 4,dq ffj, / PHONE <br /> OWNERADDRESS �. i ____ CITYISTATEIZIP <br /> CONTRACTOR /�/ �1 j. J�l�/ �P�iCf PHONE ]� 1m—) — 3 7 P l <br /> CONTRACTOR ADDRESS L CITVISTATE/ZIP Z 1 ZIA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE 911657 ❑C-61; ❑D-09 ❑Other - NUMBER Paul ION <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township e <br /> LU <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Q al try �li �;ation <br /> ❑Public Water SystemWork <br /> r ll <br /> ,. If different from Owner: aler ystem ame vY <br /> rV1 111spected-_ <br /> TYPE OF WORK ❑New Weil ❑Replacement Well ❑Well Alteration/Modification ❑ t of aJai Health <br /> —/ #of borings #of borings <br /> ❑Monitoring Well(s) #of wells Soil Boring(s) ❑Geotechnical <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pume Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION ` <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ffAuger ❑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 1 :Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other }� <br /> ' Grout Seal Depth ft ❑Neat Cement(941h hag/5-10 gal water) ❑f and Cement tack mix 17 gal water jT <br /> ❑Bentonite(20%solids) Cl Manufacturer Spec%solids % Name S� /G �� pees on File ❑Specs Sub <br /> mitt 1! <br /> IV <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name <br /> PEDESTAL Installed By ❑Driller ❑Pump Cont ctor ❑Other <br /> [3 Concrete Pedestal Dimensions: Width ft Le th ft Thick in 13Christy Box ❑Stove,Pipe (� <br /> PUMP ❑Submersible ❑Turbine ❑OE er HO <br /> Pump Set ft Standing Water Level ft <br /> ' t-IERFDv d-vu-r[F'v --A61,1 HA. F PREP D I TION T E W ED E ORDANrF WIT1H� <br /> Jt, QU 4 COUNTY )RDINr VCE , STATF W A AND 10 I S AT `JIR U LI[:AS <br /> CU RE T AND AC VE W )`A N CON CTORS S TE LICENS RD D TH I M COMI AA CE WITHrL <br /> _sRK ..,.__1PEi LA <br /> `IM A[I ^ 24 O AD NCE NO CE REQI » FO INSPECT OP <br /> A IL I 1 <br /> SIGNED TITLE ,r DATE <br /> f� <br /> FIEUP <br /> r <br /> i <br /> A <br /> Tv <br /> SA J N E T NY <br /> / E <br /> izifApl. ! <br /> FT7+7 <br /> DEPARTMENT USE ONLY f <br /> Application Accepted By at 5 (v.[ - Area -~ Em ]o ee I D# f� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ' Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> I COMMENTS v <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Into B as Remitted .Service Re uest# <br /> 1fi3.7 21 l4a23-7 .x3�-Ot7 Lb b <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> RIfi/04 <br />