Laserfiche WebLink
I= <br /> WELL 1 PUMP PERMIT <br /> JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT „ 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT I� CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1 <br /> 77((��+ •� II c�aa,, <br /> JOB ADDRESS <br /> CITY/ZIP 5I�G �/� <br /> 11f0-79-?-09 d <br /> CROSS STREET S}hg()6*- PJL—k- DX APN PARCEL SIZE �P P { LAND USE APPLICATION# <br /> OWNER NAME7`S I S eC"o I-IE I I r PHONE _ y7 7 -4&S2-.i <br /> F. ' <br /> OWNER ADDRESS n�!►�t r! C1�' CITY/STATEIZIP �Cg, 95Lo7 <br /> CONTRACTOR l? I� PHONE 7,01 -46,7 -37C3 1 <br /> rr ' t <br /> CONTRACTOR ADDRESS II 0 ? Io4 L CITY/STA TPa rx� qX1r Ti <br /> `Ir® <br /> SUBCONTRACTOR IM T PHONE may rp�j I <br /> SUBCONTRACTOR ADDRESS <br /> C[TY/STATE/GIP i IiIL t'Fay have ex If ed WI F` <br /> LICENSE CIC57.:+ 11C-61 ��❑D-09 ❑Other NUMBER XPI <br /> Ivlronm,R- - <br /> ! T wnsnip an <br /> V Ea 1 R5 oeJ�a <br /> GEOGRAPHICAL INFORMATION: COO�dinales X - <br /> INTENDED USE ❑Domestic/Private I�' ❑1Trigation/Agriculturat ❑Industrial 13Water Quality Monitoring £Soil Sampling/Characterization I <br /> ❑Public Water System antaciame o <br /> If different from owner: ater ystem ame r one Number <br /> h , A <br /> TYP£OF WORK ❑New Well ❑`Replacement Well ❑Well Alteration/Modification '❑Test Hale ❑Other <br /> #of borings #of borings <br /> ❑Monitoring Well(s) #of wells PSoil Borings) ❑Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> El Well Destruction 11 <br /> ❑New Pum . ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary !Auger ❑Cable Tao] ❑Push Point ❑Other <br /> Proposed Well Depth ' ft Excavation in diameter ❑Open Bottom ❑Gravel Pack!Gravel Size in diameter <br /> ❑Conductor Casiri jl in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter inThicknesslGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth _ ft ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name v1specs on File ❑Specs Submitted <br /> 'Irout Placement Method ❑Pumped ❑Other 13 Retardant/Accelerator(name) 1L- C�PEING S 'F <br /> t ❑Free Fall <br /> PEDESTAL Installed By If ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove,Pipe <br /> PUMP ❑Submersible IN ElTurbine [3Other HP Pump Set ft Standing Water Level ft <br /> Y AV REPA T 15 ION A T WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOA I COUNTY DINA E ATE S AND R 1 O T T RE E <br /> CU E C E WI T LI NI ONT TO ST E LICENSE D A THA 1 1 COMP N WITH A <br /> KE EN AW <br /> Ip U U ADV CE NOT E REQU 'O NSPEC'I1 N. <br /> i! <br />� SIGNED <br /> C/V�+yi TITLE r«.�/` UATE <br /> OIL +—+ <br /> - <br /> , s� !L.// _ <br /> C LE LV F <br /> i <br /> f <br /> I; 5 <br /> R �L - P <br /> ANNV <br /> d0 Q AL <br /> I ------ -- -- <br /> p p ENT <br /> CL <br /> l ISI I ^'" ' all <br /> i I I v ; <br /> ' M <br /> ir PARTMENT U NLY <br /> Application Accepted p Date Areaj Employee ID# r3! <br /> Grout Inspection By, �I Date ❑ SPECIAL Well Permit / / <br /> Pump Inspection By II Date ❑ WAIVER Received <br /> Destruction Inspection By IDate Constructed Well Depth ft <br /> COMMENTS If <br /> jPE 5C '" Received 'I"' eck#! Amount Date Permit! Invoice# Well 1D# <br /> Codes Info B Cash Remitted Service Request# _ <br /> P73 D Ll <br /> I <br /> r WELL PUMP PERMIT <br /> EHD 41-02-005 <br /> 915104 <br /> 1 I ' <br />