Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Averme STOcKTON CA 952056232 - (209) 4683420 <br />Pi LON-KttUNUABLL rLKMI I t.ALL (LUV1103-/by! FOR INSPECTIONS <br />r-ArIKCJ 7 YEAR FROM UATE ISSUED <br />o�✓ <br />JOB ADDRESS <br />Z <br />I�A� <br />l� <br />CROSS STREET TV APN <br />Z <br />O ()S V1I <br />PARCEL S� LAND USE APPLICATION <br /># <br />OWNER NAME� L���t(f7��C7JT��m <br />r, J 1✓C, /a Z y i~ c L <br />PHONE� <br />( <br />OWNER ADDRESS �RT7'//c}- i� `c1� �(+(�}� <br />J��c CITY/STATFJZIP <br />/ j <br />1.i 1 ra <br />R <br />CONTRACTORC.�CII�Jl� W�J <br />�I%Ip VGti I%�CF <br />CONTRACTOR ADDRESS �OD6� Al --(,i HaJ <br />let CITYISTATE/ZIP <br />//PffHONE K.T <br />V1C'11 <br />9563.E <br />SUBCONTRACTOR <br />PHONE <br />:TOR ADDRESS <br />C-57 a C-61 I D-09 i Other <br />CrTYISTATE/ZIP <br />l <br />NUMBER L'1 / �:"��' � EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />NTENDED USE Oomestic/Private i Inigabon/Agricuitural i Industnal ! Water Quality Monitoring ! Soil Sampling/Charactenzation <br />! Public Water System <br />If different ft.. Owner W.te, ys em ame a am or one Numbe, <br />TYPE OF WORK i! New Well Replacement Well Well Alteration/Modification ! i Other <br />IMonitoring Well(s) #of wells Soil Boring(s) #ofbonngs !i Geotechnical #of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal i i Cross -Connection Repair <br />4111111I`ieW Pumo b[Pumo Reolacement I Pumo Ranair i, Raise Well Casino <br />Drilling Method Mud Rotary i I Air Rotary i ! Auger i Cable Tool i : Push Point i : Other <br />Proposed Well Depth R Excavation in diameter i i Open Bottom I I Gravel Pack/Gravel Size in diameter <br />i i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in ThicknesslGauge/ASTM Sched i I Steel I I Plastic i i Stainless Steel I I Other <br />Grout Seal Depth ft i I Neat Cement (94 Ib bag/5-10 gal water) 'I I Sand Cement Sack mixl7 gal water <br />! Bentonite (20% solids) I I Other <br />Grout Placement Method I I Pumped I Free Fall I Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By I I Driller I I Pump Contractor I I Other <br />I I Concrete Pedestal Dimensions: Width ft Length ft Thick in i I Christy Box I I Stove Pipe <br />PUMP A Submersible) I Turbine I I Other HP .% « Pump Set A0 ft Standing Water Level 75 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. 1 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 />rn <br />a <br />M <br />DEPARTMENT USE ONLY <br />q I <br />Application Accepted BY"�/ �� 1 '� Date Area Li Employee ID# l' <br />r <br />Grout Inspection By Date S ECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B Cash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />So <br />no&a� <br />t <br />tHU an-uu WELL /PUMP PERMfT <br />8IeN88 <br />