Laserfiche WebLink
�r-"'VELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEYAKI�MENT 304 E WEBER A1.1--/FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INsprCTIONS fiEXPIRES I YEAR FROM DATE ISSUED � <br /> JOB ADDRESS C V II� CITY/ZIP <br /> r APN 6s 1 I 3(5 X <br /> CROSS STREET i... <br /> PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME L i PHONE ;- <br /> h <br /> OWNER ADDRESS �� LF CITY/STATE/ZIP <br /> CONTRACTOR PHONE .���• L <br /> y� r <br /> A'' <br /> CITY/STATEIZ[P <br /> CONTRACTOR ADDRESS <br /> SUBCONTRACTOR octj PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> n--,7 <br /> LICENSE C-57 ❑C'61 ❑D-09 ❑Other NUMBE.37 �`` EXPIRATION DATE [: <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USEomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring d Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact ame or one um er <br /> TYPE OF WORK--JO^NCW Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> p of bonngs 1:1 GeotM of borings <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) �, <br /> ❑Out-Of-Service Well E]Out-Of-Service Weil Renewal ❑Cross-Connection Repaid <br /> kliggall <br /> ew Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTI N dw <br /> Drilling Method�"Mud Rotary ❑Air Rotary R Auger ❑Cable Tool ❑Push Point El Other <br /> Proposed Weil Deptli a i U ft Excavation s �— in diameter ❑Open Bottom 12cravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter•, I in Thickness/Gauge/ASTM Sched'" r- ❑Stcel _Q:'lastic ❑Stainless Steel,* ❑Other <br /> Grout Seal Depth�_-_ft ❑Neat Cement(94!h heig/3-10 gu!water) JSand Cemcnt�Z i�a —3 .yuck»rix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By >-briller ❑Pump Contractor ❑ Other <br /> A <br /> ❑Concrete Pedestal Dimensions:Width , ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP �4Submcrsible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND SHAT 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 /> WORKERS COMPENSATION LAWS. <br /> NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED_ �""'- -/"'� ' TITLE.iJL�/'"'L:3 -- DATED ` <br /> F�- <br /> 5- <br /> ,( - - / /) <br /> V <br /> t <br /> ll I <br /> IT7 <br /> 1 -� -r E <br /> hiEA�FH L7EFl ENT <br /> C P RTMENT US ON Y �j <br /> L+ Area 06 mployee ID# `� 36(0 <br /> Application Accepted By ate <br /> 13 S EC1AL Well Permit <br /> Grout Inspection fay �' ' >�'�. Date C -- <br /> 5 Date ❑ WAIVER Received <br /> Pump Inspectiongyr• r� p <br /> ! Constructed Well Depth <br /> i COMMENTS <br /> F PE SC �Reccivcd Check#! Amount <br /> Date Service Ret acst# Invoice# Well I <br /> Codes Intoy Cash Remitted <br /> l 0 D9 200 �S <br /> �•' ��r, "'_./�� WELL PUMP PERMIT <br /> EHD 43-02-006 <br /> y 1/27/2005 <br />