Laserfiche WebLink
� WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 0� 304 E WEBERv-4 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED y <br /> '� 2(Q 1 IV` ITY/zIP a- > <br /> JOB ADDRESS �L�(`/� t7 <br /> CROSS STREET �Z, N A �67ARCELS E1_ 7LAND USE ON# <br /> !!� lip <br /> OWNERNAME <br /> PHONE ,f <br /> OWNER ADDRESS ��z�s7r?. 3,L�.VS�= - I o� CITY/STATE/ZIP ROSA1i �IL. I C,M' I <br /> CONTRACTOR 1"A) 6 Gn �7 PHONE O 8. �—C6/Q <br /> CONTRACTOR ADDRESS p��j�73 e ACJ /v ?H C/' 1')/V CITYISTATE/ZIP C'U 25- <br /> 374-SUBCONTRACTOR {to It�t-CQ Ips C-i l I 1✓L C1 61c, <br /> /q�N"1/C� _ PHONE p f,Nar <br /> SUBCONTRACTOR ADDRESS . 11-1 IOO ;O-,n �G.61c, 4\1 e- CITY/STATE/ZIP XA�1 �r2 �/T- %N'^ / <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER -714 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Charecterization <br /> ❑Public Water System <br /> UdiB'eamtfrom Owner. eter yemm ame nuct eme or x u r <br /> TYPE OP WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other X of borings <br /> ❑Monitoring Well(s) #of wells 'Soil Borings) <br /> /0-7,0 a of borings p Geotechnical <br /> ❑Out-Ot=Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION (� <br /> Drilling Method ❑Mud Rotary ❑Air Rotary '*uger ❑Cable Tool ❑Push Point ❑Other J'-r <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 � <br /> � �� <br /> _in Thickness/Gauge/ASTM Schell ❑Steel ❑Plastic C3 Stainless Steel ❑Other <br /> Grout Sed Depth/ —�—R lj(Ncat Cement(94 Ib bag/5-/0 ga/warer) ❑Sand Cement sack mix/7 gal Water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ;SF,.Fall 'b�Other 5Ov I ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length it Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ftp? <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE6 10SI S — DATE ? ®� <br /> uM <br /> 4-1 <br /> I 1 <br /> � � P <br /> O <br /> t JIM <br /> VI <br /> O MIT 111 <br /> ENT <br /> tWIPIrl <br /> Application Accepted y Area / �J� Employee ID# <br /> Grout Inspection By Dete ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth <br /> COMMENTS 4- z <br /> PE Sc Received hada/ Amount Date �-�s <br /> Invoice# Well ID# <br /> Codes Info B ash - Remitted Serv73 — a as O -. <br /> WELL PUMP PERMIT <br /> EUD 4343406 <br /> I(1]11003 <br />