Laserfiche WebLink
WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH--eARTMENT 304 E WEBL 'E 3aa FL-STOCKTON CA 95202 - (. <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DA", <br /> JOB ADDRESS I [�(/C�C/�J CITY/ZIP c�) <br /> CROSS STREET M APN 2-C)-3- /q 0- o I PARCEL SIZE LAND USE APPLICATION# 1'g'Or -ZS <br /> OWNER NAME �` `� P NE <br /> OWNERADDRESS �j / CITY/STATE/ZIP r / <br /> CONTRACTOR �+ C �v � CJ- P NF�7�/-///,)( <br /> G <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP L/ <br /> SUBCONTRACTOR PHONE <br /> SUBCON"1'RACrOR ADDRESS CITY/STATE./ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other NUMBS EXPIRATION DATE !� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact ame or one um cr <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) a of borings ❑Geotechnical of borings <br /> ❑Out-Of-Service Well ❑ ut-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement Pump Repair - 1 <br /> WELL CONSTRUCTION r <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth fl Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 111 ❑Neat Cement(94 1h bag/5-10gal water) ❑Sand Cement sal-n mu/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) (` <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width 11 Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> Pt sip ❑Submersible WTurbine ❑Other HP__Z s_ Pump Set ft Standing Water Level ft <br /> 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> �I MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> V:;NED (� <br /> -J -^-...�I..i /V� e�fr`I/�9".", (TITLE DATE 7 Z 23/C�— <br /> J <br /> r, <br /> AN JO�Q JIN CC UN T <br /> Ell T <br /> LA <br /> D E P A R T NI E N T U S E O N L Y ! <br /> I Date � �OS Area Employee[D# <br /> Date ❑ SPECIAL Well Permit ((( <br /> > Date /D ❑ WAIVER Received <br /> ft <br /> 7.�r u� .✓lvF3G <br /> Chec Amount Date Permit/ Invoice# Well ID# <br /> Cash Remitted Service Request# <br /> 9 40 Z <br /> / <br /> WELL PUMP PER <br /> Ga t;� <br />