Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
. �. WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (109)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTION EXPIRES 1 YEAR FROM DATE ISSUED L/I <br /> JOB ADDRESS LO CiTY1ZIP �! � T�� � a <br /> p J d <br /> II T1� '+ ZtLAND USE APPLICATION# <br /> CROSS STREET 1 S I f APN I ~L� PARCEL SIZE <br /> OWNER NAME <br /> U1 LL G E QMC C EEK tS'f r L PHONE <br /> �y <br /> T -}�.♦ 40-b CITYISTATEIZIP r J 1 <br /> OWNER ADDRESS <br /> CONTRACTOR ��j] 1/�]�/ `pZ/Jy/W�1 5S PHONE 3(O �� <br /> CONTRACTOR ADDRESS '/_ .�•'�'""r ` ' - y�� �-" CITYISTATEIZIP �Z Q <br /> PHONE <br /> SUBCONTRACTOR <br /> CITYISTATEIZIP <br /> SUBCONTRACTOR ADDRESS /_rtef� <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 1(��(// 0"+ EXPIRATION DATEy 4 <br /> r GEOGRAPHICAL INFORMATION: Coordinates X <br /> Y Township Range Section N <br /> INTENDED USE 11DOmestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System Weter stem Name tact nme ne r �V11 <br /> If different from owner: Y (y <br /> TYPE OF WORK ❑New Well fl Replacement Well ❑//Well Alteration/Modificatlon ❑ eC ,,� +#ofborings <br /> ❑Monitoring Well(s) #of wells jclSoil Boring(s)_ l Z _}' f t"'Finay hale e h#�ti#t r <br /> R <br /> ❑Out-OfService Well 11 Out-Of-Service Well Rene' s-Conneetto <br /> fl New Pum ❑Pum Replacement ❑Pum Repair ork' rMg eampe d �f J <br /> or inspected <br /> WELL CONSTRUCTION Y Environm-' ai Health Division <br /> Drilling Method ❑Mud Rotary Q Air Rotary XAugerit ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 10_�ft Excavation (P in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter O <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Q Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-14 gal water) ❑Sand Cement sack mix!7 gal water ]� <br /> ❑Bentonite(20%solids) Cl Manufacturer Spec%solids % Name 5a l L l-uff&2 d s ❑Specs on File IJSpecs Submitted J " <br /> f Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> f PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> p PUMP ❑Submersible [3Turbine Q Other HP Pump Set ft Standing Water Leve] R - <br /> 1 I 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE� � CN�IDATE <br /> -- _ �A ?ROL <br /> srbcs-m <br /> r JW <br /> ow <br /> Ansel <br /> � rL <br /> A'j <br /> - <br /> _.d <br /> 'r-err E w <br /> row-errs{}, 1. <br /> ro-�ruso H <br /> ti <br /> 5 � � DAU ON <br /> 11- oriwr I� M `� E <br /> DEART,MENT US O LY <br /> Application Accepted By Date O Area Employee 1D#J <br /> Date ❑ SPECIAL Well Permit <br /> Grout Inspection By <br /> r <br /> Pump inspection By Date WAIVER Received <br /> Constructed Well Dept ` ft //JJ <br /> COMMENTS &Z <br /> A <br /> l PE SC Received Che Amount Permit/ Invoice# Well ID# <br /> pate Ser <br /> Codes Info B Cash Remitted vice Re uest# <br /> S"Roo 4 Z <br /> �aao <br /> WELL PUMP PERMIT <br /> f EHD 43-02-006 <br /> 1/27/2005 <br />