Laserfiche WebLink
WELLIPUMP PERMIT yI�'� 2 r <br /> II(SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4,15 C 1I' I' I NON-REFUNDAB I CA 209 953-7697 FOR INSPECTIONS �E�7]XPIRES 1 YEAR FROM D E ISSUED E ��Jj <br /> iJOB ADDRESS CITY/7_IP I Vl (64 <br /> N <br /> ^�l �j m <br /> APN Z �—7/ 7 .c1 o <br /> 'CROSS STREET 1� PARCEL SIZE USE # A <br /> MwIMA <br /> ps <br /> 'OWNER NAME 6� om,(� /1 L 1O/N^E <br /> (OWNER ADDRESS t 3 G C IA (t t/,CSTAT IP ` CA <br /> CONTRACTOR <br /> LA 1 PNON /�. �! <br /> 1 CONTRACTOR ADDRESS <br /> 7 I'I CITY/STATE U C4 <br /> SUBCONTRACTOR ,VI <br /> SUBCONTRACTOR ADDRESS CITYISTATFJZIP <br /> jLICENSE C-57 C-61 D-09 Other NUMB (0 ExPIRAnoN DAT TC/ r <br /> DOMESTIC WELLS PuNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System �C <br /> /� \, <br /> If Clferent from Owner water System Name Contact Name w Pnone Number <br /> JJ y `. TYPE OF WORK Wee.Well Replacement Well Well Alteration/Modification Other <br /> 1 l of boons #of borings <br /> Monitoring Well(s) #of wells Soil Boring(sl 9 Geotechnical <br /> �/�,ut-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> law Pump Pump Replacement Pump Repair Raise Well Casing ^ <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Toot Push Point Other <br /> Proposed well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_to Thidmess/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 It,bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> 'Grout Placement Method Pumped Free II Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller V Pump Contractor Other <br /> oncrete Pedestal Dimensions:Width ft Len th ft Thick W in ..Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump sed-V V it Standing Water Level 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 CONTR CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL , + <br /> WORK9RS4GWENSATION LAWS. y���• n LV <br /> M 24 H R NOT( RE ED a OR INT I I IN 1 L DArE09 953-7697. <br /> SIGN <br /> Y <br /> 10 <br /> p U/ly C <br /> ���P 7MEN7 N <br /> Application Accepted By Cate Area��,J/J"�v/ Employee ID#.� <br /> Grout Inspection By Date SPECIAL—Well Permit <br /> Pump Inspection By kAb-N. cnn�n+y�Date WAIVER Received <br /> Soil Boring Ins action By Date Constructed Well Depth ( ft <br /> COMMENTS � ����'� �Tj� ��f+V� / (/APE Received he Amount permit/ I S 33 7 <br /> o es � Irtofa as miffed Date Service Re uest Invoice# Well ID# <br /> I <br /> EHD+?-OE 9lOutc WELL/PUMP PERMIT <br />