Laserfiche WebLink
WELLlPUMP'PERMiT `"•. I <br /> COUNTY ENVIRONMENTAL,HEALTH_DEPARTMENT Goo EAST MAIN STREET.STocKTON CA 95202-(209)46S-3420 } <br /> NON-REFUNDABLE PERMIT 208 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> i I 3 � l� CITYILtP � y <br /> Jos ADDRESS - v -- -- -- y <br /> 4 6 i <br /> CROssSTREIT +� -ga 'f APNj h'q< <Gn/-�r9 PARCEL Sin •� LANDUSEEAPPLICATION <br /> OWNER NAME <br /> OWNERADDRESS s CITYISTATEIZIP (� �/�y (' I <br /> CONTRACTOR > �P�HOONSE }3�3T� Z L 1- <br /> CONTRACTOR ADDRESS CITYISTATEMP <br /> SUBCONTRACTOR <br /> suscoNTRAGTDRADDRESS 1 CITYISTATEIZIP �+ <br /> LICENSE , 57 D C-61 ❑D-09 ❑Other NUMBER �_ EXPIRATION DATE _ C`" 1 <br /> GEOGRAPHICAL INPORMATION: CDordinateS X Y Township` Range 'Section <br /> INTENDED USE DomestICJPrivate ❑lrrigationlAgriculturak ❑Industrial ❑Water Quality Monitoring ❑Soil 5amplinglChareclerizaton <br /> ❑Pubic Water System <br /> I I n dlffemrdhorn Owner. WiRr system Name c4 madryambrenoneNumber <br /> i <br /> TYaE OF WORK }tC(lew Well p Replacement Weil ❑Well AiterationlModlfimuon ❑Other <br /> ❑Monitoring Well(s) #of wrens D Soll Boringrt 0 borings s} ❑GeotechnlCal rt of bedngs <br /> t 10 ut-OfSrvlce aWell ❑Out-Of-Service WDII Renewal ❑CroSs-Connection Repair <br /> 1 '141—P.mn ❑PumAcphioament ❑Pump Repair <br /> Y,JTELLCONSLRLCN d <br /> Drilling Method.1 15 Mud Rotary ❑Air Rotary ❑Auger El Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth��ft ' Excavation�_in diameter ❑Open Bottom ravel PacWGravel Size in diameter lti <br /> l ❑Conductor Cas ng in diameter I Conductor Casing Depth ft `- <br /> ` Well Casing Dlametor,6_in ThicknesslGaugeIASTM Sched`mc ❑Stec! Plastic--a Stainless Steel ❑Other 1 <br /> j. Grout Baa! Depth wZ 1tQ - R ❑Neat Cement(94 Ib bag/r10 0 water) p$and Cement -�sack mhd7 gal water <br /> i D Bentonite(20%solids), ❑Other <br /> Grout Placement Method)4Pumped ❑Free Fall 0 Other C Retardant I A xalerator(name) (iy <br /> PEDESTAL Inatetled By Arillr ❑Pump Contractor a Other. <br /> D Concrete Pedestal Dimensions:Width__'I`ft Length It Thick in ❑Christy Sox ❑Stove Plpe <br /> i <br /> pALm_p Submerskbloo Turbine D Other IHP Pump Set- _- ft Standing Water Level ft , <br /> I HEREBY CERTIFY THAT 1 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 /> -WdP)(btS COMPENSATION LA4(tS� ..-r - . , -.�-+/�-�....{ .r.... .1. - <br /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR ENSPECTIONS C 7 <br /> SIGNED TrtLE '�"" DATE <br /> ` I <br /> by <br /> EH <br /> II` O <br /> l <br /> 1 I <br /> G <br /> s <br /> aLEIN <br /> P <br /> D'-E-P-;'i2-T'M-EH'T S-EY�O`M1= <br /> Application Aompted By ~� Data Area ,.....� Employee Im <br /> j Grout Inspectlo Date CI SPECIAL Well Permit ' <br /> Pump Inspection / Date ❑ WAIVER Rereived <br /> Soil Boring Inspection By Da Constructed V*u Depth R <br /> COMMENTS <br /> PE SC Received he Amount PelTnitl <br /> Codes Info By sh Remitted Date Service Recuest# Invoice# Weil 10# <br /> 3(o& ceO VL,6P, 904- c $ . o,2 7367 <br /> j y3�r� oso so.V0 ff5,07 <br /> ii/� vrn� Cups �saa[ z <br /> WELL BUMF PERe'� <br />