Laserfiche WebLink
WELL/PUMP PERMIT ` .- n D <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN- 868 EAS-HAZELTON AVENUE-STOCKTON CA 95205-(209)468-34ZO I V <br /> ,i <br /> NON-REFUND E PERMIT CALL 2091 953-?89%SCR INSPECTIONS EXPIRES YEAR UW4TE I5 LIED <br /> jCa ADDRESS _ CITvZ y L� <br /> m <br /> ICROSS STREET (/�r "' N e4)I PARCEL SIZE • LAND U E APPLICATION Yr I p <br /> OWNER NAME �t10NE " L & I M <br /> GG <br /> OWNER ADDRESS �J /�/�� �,/�F CITY I <br /> CONTRACTOR • / e,' 1 I 14 r/� 3 PHONE W <br /> CONTRACTOR ADDRf�$ V' t' I� T A E/ZI h D <br /> SUBCONTRACTOR 'IV PHONE <br /> I <br /> SUBCONTRACTOR ADDRESS N 1A CITU/STATFJZIP r <br /> LICENSE C•57 C-61 D-09 Othe 1 NUM )_(2CD ID,. .DATE <br /> DOMESTIC WELL SA,/GLING: General Mineral/Coliform Bacteria(4391.i Dibror ochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private Irrigation/Agricultural Industrial 'Nater quality Monitoring Sal Sampling/Characterization <br /> Public Water System O <br /> if Elnerent fi.ZI N Rr. Nater System dame Contact Name orPnpne Number <br /> TYPE OF WORn Neo;Well ReOlacemert Well Well ALeratioMocif.cation Other <br /> tt d borings 1� <br /> MonnorngLVelltsj 0o wells Soil 3,,^r.res. aof boring: Geotechnical <br /> Out-Of-Service Well ail Renewal Cross-Connection Repair S� <br /> New Pump Pump Replacement i r— Rel:alr Raise Well Casinq <br /> WELL CONSTRUCTION —� <br /> i <br /> Drilling Method Mud Rotary Air Rotary Auger Caoie-Co. Dish Point Other <br /> Proposed Well Depth ft Excavation m dia,.eter Open Bottom Gravel Pack/Gravel Size In diameter ^`\� <br /> Conductor Casing in diameter r Connector Casing Depth ft <br /> Well Casing Diameter_,n Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b baglS-1G gai water) Sand Cement sack mix!7 gal water <br /> Bentonite(20%solids) Other ^ <br /> Grout Placement Method %mped Free Fall Other Retardant!Accelerator(name) ALJ` <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> oncrete Pedestal Dimensions:Width_ft Le ft Thick i .Christy Box Stove Pipe <br /> ff <br /> PUMP V Suomer le Turbine Other HP Pump Set It Standing Water Level It <br /> I HEREBY CERTIFY TAT 1 HAVE P PARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN i <br /> JOAQUIN COU DINANCES TATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS C <br /> CURRENT AN A E WITH^E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS ATION WS. <br /> 1 2 UR ADVANCE NOTICE REQUIRED=CR INSPECTIONS-PL SE CALL(209)953-7697 <br /> SIC-NED TITLESM 110"BlI DATE <br /> i <br /> i A, <br /> I I <br /> I Pft <br /> MENT <br /> Fp <br /> SEPA-A 01 <br /> 19 20 <br /> ! I Ty Rop ENT ry <br /> i ART�yFNT <br /> I i <br /> PARPMENT <br /> ®USSj? 0)1LV /� <br /> Aool, on Agceptec 8y Cate Z/( i( 9 Area �/ Employee ID# <br /> 3' .t inspecccn By Date--'�~===777""—T Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Sail Sonno Inspection By Data Constructed Well Death h <br /> PE I SC Received Ch Amount D CP Permit/ <br /> C e Irtf 8YPA ash ittec Invoice# Well 10# <br /> Service Request x <br /> W. 00400 88 <br /> I <br /> i <br /> i <br /> I <br /> WELL:P;IMPPE-R61IT <br />