Laserfiche WebLink
WELL/PUMP PERMIT <br /> t _ SAN JOAQVIN COUNTY ENVIRONM/y'r�TAL HEA IED PARTMEMf MFAST MAW STREET-STOCKTON CA 95202-(209)46¢3420 <br /> NON-REFUNDABLE PER.Ml, ��/ % ">1 9"1 'F.o°":�'+!`. "t s l r. �� EXPIRES 1 YEAR FROM DATE ISSUED <br /> a,f�s� �,C�/ 2� ��� -z _� ti�EAl, ��9ssj <br /> Jon ADDRESS CrrY _ <br /> CROSS STREET / ©I 1 APV_O -_ PARCEL SIZE _ <br /> y�il/ �a/2.5�E�S' �oLDGQ E.yo�fr NE 32�-5 <br /> OWNER NAME <br /> OWNER ADDRESS V r� CITY/STATErLtP 7 9 <br /> CONTRACTORV. ��� TROVE ^ • //�// <br /> CONTRACTOR ADDRESS /D`O Cr1Y/SrATwW <br /> SUBCONTRACTOR PBorm <br /> SUBCONTRACTOR ADDRESS CIIVISI'ATEMM _. <br /> LICENSE Cl C-57 C-61 ❑D-09 O Other NUKBER 7 ExrIRATlor1 DATE. ! - <br /> GEOGRAPHICAL INFORAt.AT1ON: Coordinates X Y Township-_ Range__ Section <br /> INTENDEDUSE ❑Domestic/Privatc Irrigation/Agricultural E3 Industrial 17 Water Quality Monitoring ❑Soil Sampling/Chameter'ristim <br /> ❑Public Water System — —— <br /> [fdiff,—.,,—.,f t Owner w.ter Sy—Nave Cu N.tnc.14..Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Altcration/Modification ❑Test Hole ❑Other-- <br /> 0 <br /> tha❑Monitoring Wells) ntwbrrofwens ❑Soil Boring(s) _ ntmdtcrofaxina. ❑Geotechnical omiber oftatio@t <br /> ❑Well Destruct:on ❑OutOfScrvice Well ❑Out-Of-Service Well Renewal <br /> NeW Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELLCONSTRUel-14NN <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other_ <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bolcom ❑Gravel Pack/Gravel Size___in diamctcr <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/GauWASTM Schell ❑Stoel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 1b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submiucd <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDtS'I AI, Installed By ❑Driller ❑Pump Contractor ❑Other___- <br /> ❑Concrete Pedestal Dimensions: Width_fl Length_It Thick i ❑Christy Bos 0a Pipe <br /> Pt.IMP ubmersible Turbine ❑Other HP Pump Ser R Standing Wafer Level R <br /> WELL DF_STRVCrI r, ❑Open bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter__in Total Depth ft Depth to Water __ft ❑Casing to be Perforated from _ R to It <br /> Sealing Material ❑Neat Cement(94 1h bag/5-10 gal water) ❑Sand Cement ___rack mix/7 gal water ❑Bentonite Pcllets <br /> ❑Bentonite(20 solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other_ - <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> 1 REREBY 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO, <br /> 4 HOUR ADVANCE NOTICE/REQ! 1,FOR INSPECTIONS <br /> SIGN ------ - TITLE (/�/V --------- DATE..._ <br /> I <br /> PAi <br /> . Air <br /> �jet V�e® <br /> • — <br /> ° 2019 <br /> fv"yMAI <br /> couof 17— R �TYTMENT YApplication Accepted By Date Area _ _ Empl <br /> Grout Inspection By Date 13 NPECIA Well Permit <br /> Pump Inspection Byll/idDate ❑ WAIVERReceived <br /> Destruction Inspection By Date Constructed Well Depth_ ft <br /> COMMENTS <br /> PE SC Receired CheekJN Amount Date Permrtl Invoice N Well ID# <br /> Codes Info BY gemitted Sen ice RequV3t N <br /> EHD 43-02-006 WEB Well Permit­J Dt claraaon d. <br /> 9/11/2007 <br />