Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(2D9)463-3420 <br /> • NON-REFUNDABLE PERMIT _ CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 2tl:s� CITYIZIP lr�!- �( . tA" 'Ps3,y g <br /> JOB ADDRESS +'� <br /> CROSS STREET �(/t/}r �/ L APN � -���'1A PARCEL SQE 7.-_ LAND USE APPLICATION*IZ ,/`/, <br /> OWNER NAME '/V 1k /Nr`.h ',�`/,� y� ` PHONE/1 ? 7 .5V- <br /> GINNER ADDRES6 I �.,6, &-,V►C�(A�"��/KA �l CA <br /> CITY/eS.TATEIZIP����yO <br /> •y-;r.\ �M�eemf!iK CM` �/1/� PHONEi��-g34�z89c <br /> CONTRACTOR ADORESS L ll{r L '0 Tr CITYISTATEIZIP I�r`>/ Qsji{°,of <br /> SUBCONTRACTOR SEAL ,1^,' 1 _I ,yPHONE I-Z�� as-VI • 1 <br /> SUBCONTRACTOR ADDRESS 1 Y-S7 /� ��'e� �V CITY/STATE17P &116" C* T 2"C1 <br /> LICENSE C-57 V.C-61 D-09 O�teh`er .e a' NUMBER�rBio 3 ff5 EXPIRATIONDATE 16!-4%S <br /> GEOGRAPHICAL INFORMATION: Coordinates ...12 -$79711><G Y II ��70l• Township_ Range Section_ <br /> INTENDED USE Domestic/Private Imgation/Agricultural Industrial Water Quality Monitoring WI Sampling/Characterization <br /> Public Water System <br /> If diff—t Iron Owner. -- a Y. <br /> am ame Wei <br /> TYPE OF WORN New Well Replacement Wel WellAlteration/Modificationt bon <br /> 111115(111111111 k- <br /> Monitoring Well's) #Df wells Soil Boring's)�_. <br /> Out-Of-Service Well Out-Of-Service Wel Renewal cd n Rep' U! <br /> New Pum Pum Replacement Pum Repair {jy- Ln 1 I <br /> COMTRUC <br /> Drilling Method Tl Mud Rotary Air Rotary XAuger Cable Tod Push Point�r�/QrOIILdle���-VVI'1 etedorins� Lad <br /> Proposed Well Depth N Excavation _in diameter Open Bo rf � t�dtfvi Ion <br /> Conductor Casing in diameter I Conductor Casing Depth [ <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seel Depth N Nast Cement(94 lb beg/5-10 gat eater) San/d Cement sack mixf7 gal water <br /> Benton@e(2010 solids) OtherM- <br /> Grout Placement Method Pumped Free Fall Other Retardant/Acceleralor(name) <br /> P t jam, Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> Submersible Turbine Other HP Pump Set It Standing Water Level h <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIII 24 HOU=ACE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> A Ty <br /> Io <br /> A DEPARTMENT USE ONLY <br /> !�I-' 1 � Area d Employee IDI <br /> Application Accepted By Date <br /> Grout Inspection By Date -_—_ SPECIAL Well Permit <br /> WAIVER Received <br /> Date <br /> Pump Inspection By --- <br /> Soil Boring Inspection By Date Constructed Well Depth h <br /> COMMENTS <br /> PIES C Recelved ec Amount +Dat e Pe mill <br /> Invoice# Well 10# <br /> Codes Info B s Remitted Service Re uest# <br /> EHD 4306 WELL RUMP PERMIT <br /> 4130112 <br />