Laserfiche WebLink
'I <br /> ur 0(11,11.202:45p Ken Gross Wells&Pumps 2097458584 p.2 <br /> WELL/PUMP PERMIT <br /> / SANjOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> �J NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB A DRESS ��> ✓/ r�-i I ' � � � �� CITYIZIP [+I!/!/ -- o <br /> ' C 1 APNyLN _L� %�L� PARCEL SIZE 410 LAND USE APPLICATION/ O <br /> CROSS STREET ]] AjJNF <br /> OWNER NAME C PHONE��„/ ? A <br /> OWNER ADDRESS J�P' - A CRY/STATE/ZIP - - --�� ;;2, <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS ✓ / rn ^ u`)z�y1 <br /> CITY/STATE/ZIP l�I � -L7. -7 p✓ <br /> I <br /> SUBCONTRACTOR _ PHONE i <br /> SuscoNTRACTORR ADDRESS CITYISTATE/ZIP <br /> LICENSE 961; 0 C-61 C 0-09 7 Other NUMBER EXPIRATION DATE I <br /> GEOGRAPHICAL INFORMATION. Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ]DomesdcfPrivate Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterizalion <br /> i <br /> 7 Public Water System <br /> ItdlNerent Imm Owner. ------------W-afer7SysrernNama L4M.ad Nams Cr Fhonaiftnlbef <br /> TYPE OF WORK ¢W Well 0 Replacement Well 0 Well AlteratioNModification =Other <br /> K <br /> *Monitoring Well(s) #of wells ❑Soil BoringY of borings 7 Geotechnical of boringss) <br /> 7(?A-Of-Service Well 0 Out-Of-Service Well Renewal =Cross-Connection Repair <br /> wl�ew Pumo D Pump Replacement O Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger klCable Tool C PushPoint -- Other <br /> Proposed Well Depth�1 J <br /> ft Excavation in diameter - pen Bottom 7 Gravel Pack/Gravel Size i:diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Tnickness/Gauge/ASTM Sched 1443 teel :5 Plastic C Stainless Steel C Other <br /> Grout Seal Depth 0 JZ fl 0 Neat Cement(94 lb bag15-10 gal water) Sand Cement f p I -3 sack.mixrT gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller O Pump Contractor 0 Other <br /> 0 Concrete P destal Dimensions:Width H Length K Thick in 0 Christy Box C Stove Pipe <br /> PUMP 1 eSubmersibleo Turbine O Other HP /yD Pump Set ft Standing Water Level ft <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M IMUM 24 HOUR A NCE NOTICjE�I/REQUIRED FOR INSPECTIONS / { <br /> SIGNED i-I✓"'r TI 11W1 r Z r DATE ! f I <br /> n - - <br /> i L - <br /> ii 2 u - ^1 - G �_• <br /> i <br /> �iJ 5 F <br /> I <br /> : I <br /> � 4 I <br /> i <br /> li <br /> i f <br /> Y DE ART NT USE ONLY -. — -- '--- - --- :. <br /> Application Accepted By ate L' Area Employee 10;X t J/ . <br /> Grout Inspection r Date O SPECIAL Well Permit <br /> Pump Inspection - Date ��_ 0 WAIVER Received <br /> Soil Boring fns ecdon y Date Constructed Well Depth ft <br /> CO MENTS J U .47 <br /> Zl' /.tJ le - /5 !ly �f�rr. n 1 E: Cd/' w# A`I✓4': <br /> r , <br /> PE SC Received Check#/ Amount Date Permil/ Invoice K Well IDK <br /> Codes Info I By Cash Remitted Service Request# <br />