Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAouiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 55202-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED I <br /> to `' <br /> Jos ADDRESS oalE.tnAri.ry5a CITYMP <br /> n n 1 D <br /> CROSS STREET• ., p C APN SCD -.M—y) PARCEL$IZE —D USE APPLLIIICATIO(N�#/�� y m <br /> OWNER NAME � F1�Liyit/ PHON�E��P+ <br /> OWNER ADDRESS OI IlQS� .�//��.�y�/1l-� CITYISTATE21P e-�C.GCi 171 <br /> CONTRACTORLNG I,Y/] 4_ `✓/n}�17 ✓ fi i P�HONCE217- ,-- <br /> /ZI <br /> CONTRACTOR ADDRESS' ✓� J /• �)///�Il[� INT CITY/STATEP V/Nif.'.T,_ <br /> �T I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 0 C-61 D D-D9 D Other NUMBER P /a EXPIRAT1oN DAT rf "�l d6JR> <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township_ Range Section <br /> INTENDED USE 0 Domestic/Private Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization }1 <br /> 0 Public Water System <br /> If different from Owner. contact Naxne,or PhDM Nur <br /> TYPE OF WORK (�LNew Well 0 Replacement Well 0 Well Alteration/Modification D Other <br /> 0 Monitoring Well(s) #of wells D Soil Boring(s) sof borings O Geotechnical ti or borings <br /> 0 Out-Of-Service Well O Out-Of-Service Well Renewal D Goss-Connection Repair <br /> 0 New Pump D Pump Replacement D Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary D Air Rotary 0 Auger Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth �51I` it Excavation in diameter Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter ! Conductor Casingpth_ft <br /> Well Casing Diameter,yin Thickness/Gauge/ASTM Schede -'lL&.ei O Plastic D Stainless Steet 0 Other <br /> Grout Seal Depth !%JZ ft 0 Neat Cement(941b bag/5-i0 gal water) 0$and Cement sack-rn&7 gal water <br /> 0 Bentonite(20%solids) D Other <br /> Grout Placement Method D Pumped O Free Fall O Other O Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width s It Length_a ftThidc In O Christy Box ❑Stove Pipe I <br /> PUMP D Submersible0 Turbine 0 Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT t 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 TkfAT_MY REQUIRED+L-(CENSE <br /> CURRENT AND ACTIVE WITH_THE CALIFORNIA CONTRACTORS STATE-LICENSE BOARD Ah-fD THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEgSATH}N LAWS. <br /> 1�N1�VAUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> 6 <br /> SIGNED— �'�� TI L=—=-=- DATE�"Ot-J / (^ <br /> c K�l <br /> ILA <br /> i <br /> V <br /> I <br /> tI` <br /> ;f <br /> "1H O <br /> D E P ATt T M -T-'U S'IE O-N Y ENVIHoEP Et1T <br /> Application Accepted By Date Area Employee IDA q0 <br /> r7[//r <br /> Grout Inspection By S ❑ SPECIALWell Permit I Q� <br /> Pump Inspection By <br /> Date 3v U ❑ WAIVER Received <br /> Solt Boring insp 'o By Date Constructed WeII Depth ft <br /> COMM NTS -, c r a <br /> ;u IF <br /> d G <br /> E SC Received Check Amount Date P. -U <br /> Invoice# Well ID# <br /> Codes Info B Cash Remitted Service R uest# <br /> Lim DIS wlv�o U Oa 3 5Y k <br /> o ' Nv <br /> E146:43.06 WELL/PUMP PERMIT <br /> ''�+c9r2�607 <br />