Laserfiche WebLink
v WELL/PUMP PERMIT <br /> k <br /> SAN JOAQUINCOUNTYENVIRONMENTALHEALTH DEPARTMENT 304EWEBER AVE3f9FL-STOCKTONCA95202-(209)463-3420 <br /> I NON-REFUNDABLE PERMIT i CA d.: 209 953-7697 FOR INSPECT1'IONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JODADDRESS CrrY1ZTP 74ct-4n, G / [..,♦ <br /> CROSS STREET - APN I 2-6 _a- �14 PARCELSIZE3°Iac. LAND USE APPLICATION 1 // <br /> OWNER NAM- {�1rl iJe.C' T r..IE.9-� aY1P_�Il :l - - - -- PHONE j 0q-5,qA- 5660 N <br /> OWNERADDRESS P�' eox, ?4000 CrTYISTATEIZIP TV r 10C I C,4 /4,-.3+g/ <br /> CONTRACTOR , ��QQ0.0F1� SnC- n / �s PHONE <br /> i CONTRACTOR ADDRESS" 194 N• (rMCSJ aIVd. ,S�e_ CTTYISTATEIZIP i�'AC-14 CA 1 TS.�J <br /> SUBCONTRACTOR P O of r y ® c -c '-'I I i 0. C (PHONE 14 08 - 661, - 73312^7 <br /> SUBCONTRACTOR ADDRESS k f0D S11Ot V CCITVIISTTA[T�EIZIP <br /> 6 _14 <br /> LICENSE -57 ❑ 61 ❑D-09 ❑Other NUMBER l,7071 EXPIRATION DATE r 1 <br /> SUBCONTRACTOR ADDRESS �'i71� {ly �L��/ILIA CITYISTATE/Z'IP G�,OJ e51r <br /> ow <br /> IU <br /> Ildifierrnt frznn Oumcr ler ynem vmT e" °,°G � ° m`�r��� <br /> h <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other Out <br /> N°f bn ngs l <br /> ❑Monitoring Well(s) N of wells $oil Boring(s�0-9 d hGeote!cnhnica °p n 'e <br /> Q(� <br /> •Out-Of-Service Well C7 Out-Of-ServioeWell Renewal ❑Cross-we*lbeiI[g completed ori 'eted <br /> ❑New Pum ❑Pum Replacement ❑Pum Repair { €€tt (�t't Yp ] p�j <br /> WELL CONSTRUCTIONII 1„[i ror�m,. ..d Ea I�1 �lol� <br /> by <br /> Drilling Method ❑Mud Rotary ❑Air Rotary .Auger ❑Cable Tool ❑Push Point 0 Other <br /> Proposed Well Depth! d It Excavation min diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter 1 Conductor Casing Depth P <br /> Well Casing Diameter in Thickne551CjaugelASTM Sched ❑Steel ❑Plastic ❑Stainless Steel 13 Other <br /> Grout Seal Depth ft '�- eat Cement(94 th bag/S-10 gat mater) ❑Sand Cement .sack mix 17 gal water <br /> y ❑Bentonite(20%solids) Manufacturer Spec%solids__u___% NL Q Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped .Free Fall Other - '.I A ❑ tar ant ccelerator(name) <br /> r PEDESTAL Installed By ❑Driller 0 Pump Contractor ❑ Other <br /> ❑Concrele Pedestal Dimensions:Width ft Length ftThick in ❑Christy Box ❑Stove Pipe <br /> uMP Sub' e ❑Tur the HP Se Wa Lev ft <br /> [HE BY CER 1 HAV EP D THIS PLICATION, THAT THE L B ONE I C DA WITH <br /> LD <br /> OA NCO O 1 NCE TE WS,A RULES AND I S. I A ERTI THAT III LICEN S <br /> PUR CTI H LI NIA C RACTORS ST E BOA ATH O IA LL <br /> WO RS C ENS O A <br /> ! lv 24 Ot1R f 'ANC.E NO'I FOIL "Y TIONS <br /> SIGNED TITLE &e.(' �5 DATE r� r D <br /> it <br /> T <br /> EN <br /> 1\/ED <br /> P��r �: <br /> G k It <br /> I <br /> KC <br /> m U <br /> SVV MF-A <br /> .s Pp,R�wlp4 <br /> V 49 <br /> T <br /> ! N ° <br /> .f DEP-ARTMENT SE ONLY ICJ <br /> Application Accepted By Date 1 a!!J Area Employee IDN <br /> Grout Inspection By Date E] SPECIAL Well Permit Tr <br /> Pump]nspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> 11 <br /> PE Sc 'iReceived h Amount ate Permit/ Invoice H Well IDH <br /> Codes Into Cnsh Remitted Service�R J uest H <br /> 7 "1 <br /> EV '77192 <br /> k UCJ <br /> EHD°3�2aNv: II WELL PUMP PERhUI' <br /> 112712N.5 <br /> .E <br /> .i <br />