Laserfiche WebLink
WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E W9BER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 } <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> S y f, CITYIZIP 'i�4�^�'O/� a <br /> szo5 <br /> JOB ADDRESS � � 4/Q � 1 ��IJ rll1� <br /> D . I�{7 APN ARCEL SIZE BLAND USE APPLICATION# �y <br /> CROSS STREET -A <br /> PHONE �O4_ [�,�Q <br /> OWNER NAME i ..tom. q <br /> OWNER ADDRESS LAJ �r �I,��k �--fes CITYISTATFIZIP�JPGIA 1-r�V�.��G"F; SJr'^� <br /> -"- Z <br /> t— <br /> N� ) d, J f o s5O PHONE f--c� -361- 31�- <br /> CONTRACTOR L'1 J <br /> yyCITYISTATEIZIP LyQ/f G A- <br /> CONTRACfORADDRESS�17` �tiouS <br /> PHONE <br /> SUBCONTRACTOR <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR ADDRESS <br /> LICENSE C-57 ❑C-61 D D-09 ❑Other NUMBER `�� EXPIRATION DATE 66 <br /> GEOGRAPHICAL INFORMATION: Coordinates X <br /> Y Township Range Section <br /> INTENDED SE ❑Domestic/Private ❑Irrigation/Agricultural [I Industrial ❑Water Quality Monitoring 'Soil Sampling/Characterization <br /> ❑Public Water Systemamc r P m e i O <br /> If different from Owner: Water System Name -� <br /> TYPE OF WORK ❑New Welt ❑Replacement Well ❑Well Alteration/Modificatian s❑ th orings <br /> arin <br /> ❑Monitoring Well(s) #of wells '. y5OilBoring(s) #ofb <br /> erRnit may <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connects n Re it <br /> ❑New Pum ❑Pum R lacement.-""•❑Pum Repair, <br /> work being competed or inspected \A <br /> WELL CONSTRUCTION , by i,-i lvironm . al Health Dlmion <br /> Drilling Method ❑Mud Rotary ❑Air Rotaryp t r F,/ ❑Cable Tool ❑Push Point ❑Other <br /> Proposed, Depth o•-10 ft Excavation Y in diameter C3 Open Bottom 13 Gravel Pack 1 Gravel Size in diameter <br /> 6okkA1,S ❑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 bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in E3 Christy Box [3 Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level 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. 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 /> MINI UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> 65- C GSE- <br /> /�Q l <br /> SIGNED. TITLE ( I S E- DATE <br /> STREET <br /> 9 11 1 3 6 7 9 Jf / is 5 7 9 If <br /> _ <br /> n 12 <br /> 1 <br /> p A � l•,R� Fi � �. 64 <br /> E - - <br /> I�` I - 8 t ,� - • ,4 ! <br /> I I <br /> si w l6b i0 �° r <br /> ra r 2 4D ro rs z a JP r2 <br /> 3SrREfiT F <br /> Q ff J' 6 <br /> f 9 9 <br /> !t 1 S S ? 9 It <br /> r x <br /> FTT <br /> - - - - - - <br /> DEPARTMENT USE ONLY u(� ' <br /> Application Accepted By eyti Date Cj Area Employee'ID# <br /> Grout inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Dep ft <br /> COMMENTS artir / 1 <br /> i PE SC Received Check#! Amount Date Permit/ Invoice# Well 1D# <br /> Codes Info By -cash Remitted Service Request# <br /> + -Z CS• 15 D ? s 0 C/ <br /> k <br /> WELL PUMP PERMIT <br /> EHD 43.02-W <br /> 112 712 00 5 <br /> 1 <br />