Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />IVUIY-RtrUNUAt$Lt rt:KMI I <br />Z.L'� <br />jZj <br />t.ALL LU`J `J53 -TUI FOR INSPECTIONS — It11�/Y�,,1//K/^'t, 'I YEAR FROM LATEISSUED <br />-7� <br />QLijj ' <br />rcr 67 <br />JOB ADDRESS <br />, <br />j ji n � <br />CITY/ZIPI _ - / 5- � 6 <br />CROSS STREET <br />APN - 0?0- <br />PARCEL SIZE V LAND USE APPLICATION # <br />OWNER NAME % I <br />` <br />PHONE <br />OWNER ADDRESS' <br />�I <br />(/ <br />ISITATI/E /ZIP 1 <br />-^ <br />�PH�ON <br />CONTRACTOR <br />J <br />(. �Cy^ITY <br />E— <br />9 13 p), <br />CONTRACTOR ADDRESS- T� / I ` �r /CITYI�TATE IPJ <br />)R / r PH,,,,d <br />)R ADDRESS IV CjTY(STATEp <br />C-57 C-61 D -09C D-09 Other NUMBER EXPIRATION DATZ 1 �( WEXPIRATION DAT <br />GEOGRAPHICAL IN�RMATION: Coordinates X Y Township Range Section_ <br />INTENDED USE •w Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name ContaCt Name or one um r <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Aut-Of-Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Pump Replacement Pump Repair Raise Well Casing <br />DrillingMethod Mud Rota Air Rota Auger Cable Tool Push Point Other <br />N Rotary 9 <br />Proposed Well Depth ft Excavation in diameter Open Bottom 1 Gravel Pack/Gravel Size in diamete <br />Conductor Casing in diameter / 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 (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft gth ft Thick in Christy Box tove P'pe <br />PUMP Submersible Turbine Other H Pump Set ft Standing Water Leve ft <br />1 HEREBY CERTIFY THAT 1 HAVE PRE R D THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STA L S, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS Q <br />CUR WITH THE C O CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />W KERS C PENSATI N LAWS <br />MIN U H R ADV CE OTIC EQUIRED FOR INSPECTIONS <br />�-/yPLEASE CALL (2091 5 7697 +0 - zJZ <br />SIGNED ATI EC/ I Y I lX ! I I Vt. DATE r � N O� <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />EP RTMENT UoI9ONLY <br />Date / <br />Date <br />Date <br />Date <br />�W <br />Z.L'� <br />jZj <br />CIV <br />ago <br />QLijj ' <br />ZS <br />, v" <br />Date <br />!/`r l� Fool 31 W <br />Area Employee <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received <br />Codes Info B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />DatPermit/ <br />e <br />ServiceRequest# Invoice# WeI11D# <br />ZS <br />, v" <br />Date <br />!/`r l� Fool 31 W <br />I VEL) <br />HE V -H <br />