Laserfiche WebLink
A <br />3 WELL/PUMP PERMIT <br />t AN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAW STREET - STOCKTON CA 95202 - (209) 4683420 <br />NON-REFUNDABLE PERMIT <br />CALL (209) 953-7697 FOR INSPECTIONS <br />1 YEAR FROM DATE ISSUED <br />Joe ADDRESS r1x <br />r Crry21P <br />/E,lXPIIIRRES <br />-✓ v!.9�� <br />/ (L L <br />_ <br />APN Q %�"' �-'PARCEL SIZE <br />USE APPLICCATION # <br />DU . <br />CROSS STREET � <br />OWNER NAME <br />OWNER ADDRESS <br />CIT'Y/STATE/ZIP <br />CONTRACTOR14 <br />CONTRACTOR ADDRESS / <br />l CRY/STATEIZIP <br />SUBCONTRACTOR )� <br />�r //� <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATERIP <br />NUMBER <br />�7 f <br />ExPIRATION DATE 3 / a <br />LICENSE C-57 -61 0 D-09 <br />❑ Other <br />GEOGRAPHICAL INr-0R1AA ION: CoOrdlnetes X <br />Y Township_ Range Section <br />INTENDED USE D Domestic/Private rrigation/Agricultural n Industrial ❑ Water Quality Mon ltoring 0 Soil Sampling/Characterization <br />If Public <br />anon; oW wr. y6 em Name CZntact Name Of Phom u <br />TYPE OF WORK D New Well Replacement Well D Well Alteration/Modification ❑ Other <br />D Monitoring Well(s) # 01 wells ❑ Soll Bodng(s) #of borings ❑ Geotechnical .of borings <br />D Out-Of-SeMce Well 0 Out -Of -Service Well Renewal D Cross -Connection Repair <br />D New Pump Pump Replacement ❑ Pump Repair D Raise Well Casing <br />WELL COdsTRUCTION <br />Drilling MethodMud Rotary 0 Air Rotary 0 Auger U Cable Tool 0 Push Point ❑ Otter <br />Proposed Well Depth- 30 It Excavation Af_in diameter U Open Bottom travel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth /` k <br />Well Casing Diameter/AQ-in � <br />in Thidmess/Gauge/ASTM Sched.Z{[(U Steel [ Plastic ❑ Stainless Steel D Other <br />Grout Seal Depth �� It D Neat Cement (941b bag/ 10 gal water) ❑ _Sand Cement sack mix/`7 gal water <br />antonite (20% solids) D Other <br />Grout Placement Method XPumped D Free Fall D Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By O Driller XPump Contractor ❑ Other <br />0 Concrete Pedestal DI nsions: Width ft Length ft Thick In 0 Christy Box ❑Stove Pipe <br />PUMP OlCubmersibleU Turbine U Other HPI i Pump Set It Standing Water Level it <br />I HEREBY CEeWi 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 />T-`,'` <br />MIN <br />�r /HOUR At1VANCE TiTICEPE¢1,U�IRE FOJ2INSPEC710NS `�r <br />SIGNE TITLE b/���.�! � �•--- _ DATE / / /e <br />■■■■■■ ■ r�C■■�I.O■ ■■■IIF/�'%711!�11011 ■ <br />■■ ■■ ■C■■ S�■ a ■■■Ill. 1i+ i l L z■■11ME11 ■ <br />■ ■■ ■■■■'■■■� r•.• <br />■■.■.'Jk ....■FPA �C'1 iW' .. L�■■ ■11a.1�■�� <br />.■■■■ ■■ti..9■■■F I�% M .Mil ■.....■11�.+�■11 <br />■■■ ■ ■ C`_ �■■ HMO ■■■■■■■ ■■�1•■ IrJ■11■■■ <br />NO <br />■■ ■ Maui■ ONE :-L ■■■■ ■■ 1■■ �■�i0 ■■■ <br />I■lr-mism ■OME MCn�.: ■■■■�■■■■I■F.�■11A�■■■ <br />■■■I■■IBM MERMN ■?OC�I,-"''I�■■■■■�■■■�■ i :�■11�■11■■■ <br />■■■I■■■■■■■■ M an :1: a ��t ■■ ■■■�■■i ■11■■ 1■■■ <br />■■■��■■■■■■■■°°IN mFNI <br />�l■ii■ii■ii■■i■ �i■■■■1 ■i <br />■■■■ ■■■■■■■■r■■■EYED% <br />LrL'.tCF3 � r , <br />