Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> G ? (� G N <br /> JOB ADDRESS 9 I �U l 1` CITY/LP A`OM n + I 2 3o D <br /> 2 1 O <br /> CROSS STREErh <br /> T '��_(l fD ✓) I�D. APN PARCEL SIZE LAND USE APPLIC/AT�ON# m <br /> OWNER NAME Cy-N PL (r7PHONE <%G (�V <br /> OWNERADDRESSD CITY/STATE/7jP�A�MC ')T.;L'acI1\ <br /> CONTRACTOR PHONE W� - �?7-7 <br /> CONTRACTOR ADDRESS CITY/STATE/ZJP G-�)1tc <br /> w <br /> G <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS �CIyN//S�TATEIZIP <br /> LICENSE C-57 -61 :..'0-09 L Other NUMBER =�")'1 SS 5 EXPIRATION -7-31 -10,DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE '/,Domestic/Private ❑Irrigation/Agricultural Industrial :1 Water Quality Monitoring ❑Soil Sampling/Characterizabon <br /> Public Water System <br /> If different from Owner: water ys em Nam o a ame or Phone NUMber <br /> TYPE OF WORK x New Well I Replacement Well I Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings ":Geotechnical Sof boring. <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum ' Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary I Air Rotary Auger 'Cable Tool Push Point i Other <br /> Proposed Well DepthQ 7 9_ft Excavation_ I',2 —in diameter n Open Bottom ')(I Gravel Pack/Gravel Size /4 - In diameter <br /> Ci Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Qj 2(0 n Steel `tQ Plastic i.I Stainless Steel ❑Other <br /> Grout Seal Depth_ Lift -1 Neat Cement(94 Ib bag/5-10 gal water) Sand Cement L S sack mix/7 gal water <br /> Bentonite(20%solids) -Other <br /> Grout Placement Method umped Free Fall I i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Wriller L Pump Contractor j Other <br /> Concrete Pedestal -Dimensions:Width�ft Length 7 ft Thick in Christy Box Stove Pipe <br /> Eu—.p Submersible Turbine Other HP Z Pump Set ft Standing Water Level 1 GO ft <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 COMPENSVft LAWS. <br /> MINIMUMID40UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9(53-7697 <br /> �-Cv <br /> SIGNED L✓ " Q TITLE �� 17��C S DATE I b - <br /> ZZ <br /> s <br /> N S,, O <br /> C�\ <br /> e � 0 0uN EN�EN� <br /> sp <br /> pg <br /> DEP RTMENT U2E O Y yn <br /> Application Accepted ByDate 3 Area ` Employee ID#� <br /> Grout Inspection By J Date :1 SPECIAL Well Permit <br /> Pump Inspection By Data d Z 3 V ] WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth OL It <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> Codes Info B Cash emitted Date Service Re uest# Invoice# Well ID# <br /> 9so flq IB �PDo3 <br /> 9SO s ► CoQ 38 <br /> E D 43-06 WELL/PUMP PERMIT <br /> 4130112 <br />