Laserfiche WebLink
WELL/PUMP <br />jSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />33 l(, O�tM IV/�1I <br />PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT / CALL 209 953-7697 FOR INSPECTIONS t1�F'IFtt, l7 TEAK I -HUM LJAtt W,UtU <br />JOB/ADD„ R� .9cl-S '14 .f�'7A~ �p� CITY/ZIP //�/ •'_ ' /"' ✓ <br />CZSS STREET / 1 V �—//v /`� APN 9060 — 40 —2,V PARCEL SIZE -�/ S LAND USE APPLICATIO/N�#y <br />OWNER NAME y, `�/ �'•���� l T� PHONE <br />OWNER ADDRESS F/01/- 15N1`�/'w� 500evr A�/���w � CITY/STATE/ZIP <br />CONTRACTOR C��O�`"��NC ��7�► PHONE <br />CONTRACTOR ADDRESS, 17/W lif'luxer'r AX9 CITY/STATE/ZIP s « 9:57 <br />SUBCONTRACTOR /i'fI • `��+bLIS� ©�/ PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 00 C-57 -61 ,I D-09 11 Other NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />INTENDED USE <br />Y <br />L Irrigation/Agricultural 0 Industrial <br />I Public Water System <br />If different from Owner: Water System Name <br />TYPE OF WORK xlew Well [1 Replacement Well <br />/D_ Monitoring Well(s) # of wells <br />❑ Out -Of -Service Well <br />Township Range Section <br />%i Water Quality Monitoring 1i Soil Sampling/Characterization <br />❑ Well Alteration/Modification ❑ Other <br />❑ Soil Borings) # of borings <br />U Out -Of -Service Well Renewal <br />ent U <br />or <br />L Geotechnical <br />U Cross -Connection Repair ;9t o+D <br />n Raise Well Casino Ci� <br />WELL UONSTRUCTION &A. �Z <br />Drilling Method,,)Pfvlud Rotsry ❑ Air Rotary C Auger U Cable Tool CI Push Point ❑ OtherWr <br />Proposed Well Depth _ ) r� Excavation _ �52o in diameter ❑ Open Bottom Ii.Gravel Pack/Gravel Size i ir4p an( ter <br />U Conductor Casing in diameter / Conductor Casing Depth / It <br />Well Casing Diametew°' i 1h i kness/Gauge/ASTM Sched C4 U Steel,.A�Plastic C Stainless Steel ❑ Other <br />Grout Seal D th__a _ft \ Cl Neat Cement (94 Ib bag/5-10 gat water) �fSand Cement `d. sack mix/7 gal water <br />I nite 2- s) I Other <br />Grout Placement Method Pumped 0 Free Fall n, Other [, Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller Si�Pump Contractor U Other <br />Concrete Pedestal D ne_nsions: Width ft Length ft Thick in ❑ Christy Box n Stove Pipe <br />ILU_ _MP _XSubmersible [ 1 Turbine 1: Other HP /l2 Pump Set /<6 ft Standing Water Level A—E- ft I <br />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. 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 />MI ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9)3-7 7 <br />SIGNED TITLEDATE L <br />t <br />SC <br />Info <br />Received <br />By <br />. . . . . . . . . . . \ <br />Amount <br />Remitted <br />Date Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />• • . <br />3 <br />.N <br />W <br />W003Us32 <br />1_1 <br />O W <br />jp( < w <br />0 <br />1 ;0 �Sfz007(�332 <br />. 2 <br />:.o.ILL <br />► a <br />60 ta <br />�'ryy 3gN iii . . . . . . . . . . . . . . . . . <br />bku 4 <br />a <br />. . . . . . . m <br />wi <br />. . . . . . . .. C /5r . . <br />.wsNwai <br />. . . . .� 2h .�. — <br />. <br />E RTMENT USE �N Y <br />Application Accepted B Date <br />Grout Inspa.Ction rl . Date <br />Pump Inspection By Date119 <br />Soil Boring Inspection By <br />COMMENTS r».w <br />TLI <br />Area 41A, Employee ID#�v� <br />F - PEC AL Well Permit <br />❑ WAIVER Received <br />Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />3 <br />Il ",o ��v �C•IL0071i3'�l <br />W003Us32 <br />1_1 <br />1 ;0 �Sfz007(�332 <br />035 1 <br />60 ta <br />���Z � /� l� II I��IIW rF% oU��'f�jT✓ I WELL /PUMP PERMIT <br />