Laserfiche WebLink
WELL / PUMP PERMIT SCANNED 1a&o .' . <br /> fSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �, <br /> 304 E WEBER A-vE 3" FL-STOCKTON CA 95202 - (209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL{209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS R IZ <br /> CITYIP <br /> t m <br /> CROSS STREET IC 1 (Jti� l�t�l1 APN iC.GtPr�IO' <br /> PARCEL SIZE�' LAND 11SE APPLICATION# D <br /> OWNER NAME _bknndo <br /> PHONE �ff�!J`'��CJ--�S� `•�•' <br /> ' r _ — <br /> OWNER ADDRESS �3 <br /> CITY/STATE/ZIP�(�� �� I <br /> CONTRACTOR t i~"'�—��� ^3 6 1 <br /> r <br /> } l ( ' + PHONE � � 1 <br /> CONTRACTOR ADDRESS 7 f� � 4 16'e +-*;- ed, � CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> )131 <br /> SUBCONTRACTOR ADDRESS CITYIyS�TATEEIZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER �J L EXPIRATION DATE.C.Lt�`C/ 6` <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rang¢ Sectign <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System ` <br /> 1fdifferent from owner, Walcr YSTM Name onlact Name or Phone Number <br /> TYPE OF WORK XNew Weil ❑Replacement Well ❑Welt Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Wel](s} #of wells ❑Soit BoHng(s) #ofborings of borings <br /> ❑Geotechnical <br /> ❑Well Destruction ❑Out-Of-Service Well ❑but-Of-Service Well Renewal <br /> ❑New Pump 0PumR Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method kMud Rotary ❑Air Rotary ❑Auger ❑Cable Toot ❑Push Point ❑Other <br /> Proposed Well Depth �22 fl Excavation /,;7 in diafineter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor,Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched &e 11 ,Mastic ❑Steel Stainless Steel ❑Other ' <br /> Groat Seal Depth _ -_ft 0 Neat Cement(94 lb hag/5.10 gal water) ❑Sand Cement sack mix/7g al water <br /> KBentonite(20%solids) ❑Ma facturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL ]Installed By ❑Driller Rump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I <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 f AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> I �l11f� /EM�INIM1/U�M 24 HOUR ADVANCE NOTICE REQYIRED FOR INSPECTIONS s� <br /> SIGNED 1A i. C, v •t 4!�Aa' TITLE :1•r I ek DATE <br /> I <br /> 21 <br /> I <br /> i <br /> "+-F�; v R O 4 M N A I <br /> j LT D P T E T <br /> - v <br /> I <br /> k <br /> 1 <br /> I <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted Date �` JArea Employee ID# <br /> Grout Inspectio By Date ❑ SPECIAL Well Permit !ff 77 7 <br /> Pump Inspection By Date i ❑ WAIVER Received <br /> Destruction Inspection By Date Const cled Well Depth ft <br /> �/ f <br /> COMMENTS GI <br /> PE SC Received hec 'I Amount Date Permit/ Invoice# Well Codes Info B as Remitted Service Re uest# <br /> 151 <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> A/6/04 <br /> i <br />