Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)668-3420 <br /> +� NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,108 ADDRESS CITY2)1P <br /> CROZ3 STREET PN - U-PARCEL SIZE�Z4k)LAND USE APPLICATION A! <br /> OWNER NAME PHON/€ ( O (/IJP <br /> OWNER ADDRESS t 't CITY/STATE/ZIP_j {r'� <br /> CONTRACTOR 10 _ PHON <br /> CONTRACTOR ADDRESS _ -_ __�--CITYISTATErIJP-,914 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/ TAT P- <br /> ILIcEN3E ' C-57 VC-61 D-09 Other NUMB Q <br /> C U EXPIRATION DATE `— <br /> GEOnRAPHPCAL INFORMANON: Coordinates X Y Township Range Section_ <br /> INTENDED USE Domestic/PrNaato nigatltlorVAgriculturel Industrial �-Water Quality Monitoring 7 Soil Sampling/Characterizallon <br /> Public Watar Syst6Tn <br /> It dmaram It 0-1 vww tyte. amn "W.ad NaPV or I-none Iumewr <br /> TYPE OF WORK Now Well Replacement Well Well AJteration/Modification I..Other <br /> /i Monitoring Weft(s) 6 nit wyUs -I Sod Borinp(s) M"r11O0f�' i_. Geotechnical a cr rcroy, <br /> Out-Of-Service Well Out-Of-Servico Well Renewal I Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rviary Air Rotary Auger � Cable Tool Push Point i i Other <br /> Proposed Well Depth L12 00 it Excavation -1-za�in diameter Open Bottom x Grarel Pock/Gravol Size In diameter <br /> Conductor Casing In diameter / Conductor Casing eplh ft <br /> Well Casing Dlanwterl in Thickness/GaugWASTM Schad /M&v'4l/Steal Plastic 1: Stainless Steel Other <br /> Grout Seal Depth_50_R .I Neat Cement(94 Ib bagr5-10 gal water) $and Cement A0, Sack mix17 gal water <br /> Bentonite(20%solids) I Other <br /> Grout Placement Method 19Pumped Free Fell Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller u Pump Contractor Other <br /> Concrete P estai i Dimensions Width"f1/ it Length k Thick In Ctyisty Box Stove Pipe <br /> PMP rYSubiTtarsible Turbine i I Other _ HP-,(aO Pump Set ft Standing Water Level It <br /> I 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M /'l�-�ILLP/'J�' A/NCEJNOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953- 697 <br /> SIGNED <''V LII�IV TITLE DATE I _ <br /> r Jr C <br /> C <br /> Ncj <br /> 0. <br /> DEPARTMENT U—l� ; l l `�-V <br /> Application Accepted /Date Area by �� Employee IDS <br /> Grout Inspect By- i .'..Date. SPECIAL Well Permit <br /> Pump Inspection By Dote ... WAIVER Received <br /> Sod Boring Inspection By Data Constructedell Depth R <br /> COMMENTS al k v <br /> PE SC R Iwd he Amount Date PernuU Invoice III <br /> Well ION <br /> Codes info 8 ash Remitted Service Re est A <br /> 4\3618 <br /> EhfD�.OS L:.0 c_ C.r•C[�../J C-.y'Yl�r )l.Ci ',3 WELL.IPU1dP PERMIT <br /> J,�t}Jt7 <br />