Laserfiche WebLink
WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 344 E WEBER AVE 3R°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT If CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> r --20 2- N. 'Alt4 0( <br /> CTTYIZiP <br /> u-'t_o t ) CIS 2 <br /> JOB ADDRESS 1 � L D C I <br /> CROSS STREET N ►�1Al2 6Ci`1� I� S T. APN PARCEL SIZE/6�LAND USE APPLICATION# <br /> y <br /> OWNER NAME T m 1 I �— ' PHONE <br /> OWNER ADDRESS j �) 2 J �/�✓�V ��e�7 nn a _ CITYISTATEIZIP 4-t OL MGTdt� + Z <br /> CONTRACTOR C{ I� �( Lt Frt SS Ll►�TS�� PHONE ��� '�-y 3-,0r <br /> CONTRACTOR ADDRESS I� CITY/S k/ZIRAIV <br /> SUBCONTRACTOR I HILD <br /> SUBCONTRACTOR ADDRESS I CITY/STA 11P ' p�/ (may <br /> ,J/ i P th0ut <br /> LICENSE CJ[-57 ❑C 61 I D D-09 Cl Other, NUMBER t1 1 1 TION ATE p <br /> jqlp <br /> Aq <br /> GEOGRAPHICAL INFORMATION' Coordinates X 1' TO� - .R 'ntle� <br /> f_i <br /> INTENDED USE ❑Domestic/Private J[ ❑irrigation/Agrieultural 13 industrial [3 Water Quality Monitoring o 1 talti ttan <br /> ❑Public Water System <br /> 1f different from Owner: Water SyStern Name Contact Name or Phone Number <br /> SIM <br /> TYPE OF WORK ❑New Well O Replacement Well ❑Well Alteration/Modification ❑Other a of borings <br /> ❑Monitoring Well(4 #of wellsSoil Borings) . of twdagr ❑Geotechnical <br /> IS <br /> ❑Out-Of-Service Weli ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pumn 17 Pump RelDlacemcnt 13 Pump Repair <br /> WELL CONSTRUCTION 1111 <br /> Drilling Method ❑Mud Rotary �qII``❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth �� 1IN ft Excavation in diameter ❑Open Bottom 0 Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casingin diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched - ❑Steel ©Plastic ❑Stainless Steel ❑Other <br /> E - sack mix 17 a!water <br /> Croat Seal Depth TM.L.L-�'I�' ft Neat Cement(94 I6 bag/5-10 gal wader) <br /> ❑Sand Cement <br /> g <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ©Specs Submitted <br /> iI <br /> Grout Placement Method ❑Pumped Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ' II Other <br /> [3 Concrete Pedestal Dimensions:Width N Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> k ft <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump ft Standing Water Level <br /> 3 AN <br /> REP D IIS ___- ._ TION WO DO 1 A S. <br /> j04U COUNTY RDINA E ATE W ND R LES AND GULATION I SO ERTi T T Y RE R SE S <br /> C 7 AL I CONTI 1CTORS S NSE RD DTH 1 I COM A E WITH A L- <br /> WOR S COMPE TI A ,I <br /> f 4 OL t o ACE NO E O INSPEC <br /> SIGNED TITLE i DATE �2 + <br /> ,I <br /> II` <br /> IE� <br /> 1f <br /> If <br /> �t <br /> SIE <br /> iI Jill 1:1 <br /> I� <br /> �R J10 <br /> IM <br /> A T <br /> ART U E O LY <br /> i622t�.i y� <br /> Application Accepted ByDate Area Employee ID# <br /> Grout Inspection By `IDate ❑ SPECIAL Well Permit E J <br /> Pump Inspection By �IF Date ❑ WAIVER Received <br /> Constructed Well Depth <br /> I 4, R <br /> k I� <br /> COMMENTS <br /> PE SC ReceivedChec Amount Permit/ Invoice# WeIIID# <br /> Codes Info By Cash Remitted Date _Service Re nest# <br /> "22t a S'�-� -3 a s; - v v 4 3 2--7 T <br /> li WELL PUMP PERMIT <br /> EHD 43-02.006 <br /> tmr2oa5 !!! <br /> �f <br />