Laserfiche WebLink
WELL / PUMP PERMIT <br /> jA,q JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 344 E WEBER AVE 3N°FL-STOCKTON CA 95202- 209 468-3420{ } <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> t �O S ISS c A-(-0 _ E L c c <br /> � „ . 7 <br /> f <br /> �SQl(JOB ADDRESS MCIT CaZ <br /> j ' /CROSS STREET APN RCEL <br /> 9v <br /> SIZ LAND ZJSI:APPLICATION# ap <br /> f <br /> OWNER NAME PHONE <br /> Tined , <br /> OWNER ADDRESS S CITY/STATE/ZIP <br /> CONTRACTOR /�(.�tJe�/[,J V�G�(I - PNONE �- - <br /> CONTRACTOR ADDRESS ,.('/�n`�Jj q <br /> -- �7 • �• CITY/STATFJZIP I <br /> 1*5,1`1040 -a r. < .. <br /> SUBCONTRACTOR PHONE e- <br /> SUBCONTRACTORADDRESS- CITYISTATEIZIP <br /> �c Z/ <br /> LICENSE C-57-,r ❑G-61 ❑D-09 ❑Other NUMBER E27�L-�— EXPIRATION DATE <br /> a <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br /> INTENDED USE estic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ©Sail Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name— <br /> TYPE <br /> ame TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification D Test Hole ❑Other <br /> 13 nitoring Well(s) #of wells ❑Soil Barin s #of borings #of borings <br /> g( ) 11 Geotechnical <br /> El Well Destruction ❑Out Of-Service Well ❑Out-Of-Service Well Renewal <br /> # ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Toot ❑Push Point ❑Other <br /> Proposed Well Depth -76-0 ft Excavation_ in diameter ❑Open Bottom ravel Pack I Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft 1 <br /> I <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched -� ©Steel lastic 11 Stainless Steel ❑Other i <br /> i Grout Seal Depth �tt ❑Neat Cement(94 lb hag 15-10 gal water) ❑Sand Cement -sack mix/7 gal water <br /> XBentonite(2O%solids)' ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other 11 Retardant/Accelerator(name) C�3 <br /> PEDESTAL Installed By ❑Driller rump Contractor ❑Other w 1 <br /> ❑Concrete Pedestal Dimensions: Width R length ft Thick in 0 Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water level ft <br /> r WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> '1 Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft <br /> Sealing Material ❑Neat Cement(94 lh bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other X. <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad C <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN AC70RDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 /> MINIMUM 24 YOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS (}T <br /> SIGNED L' [i LL4'�G TITLE.- tr� l� - .,. DATE `-" <br /> ire <br /> IV ENT <br /> 3 � <br /> "} ! <br /> / <br /> Q <br /> y <br /> �s <br /> F <br />�3B . A 111 c U <br />