Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 95202 - (2091468 vi2n <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JoeAOOREss `I yz� ' • [d {-P-!2 Y� n �y CrrY/ZIP aCiCAA:7;?7ii gS2.IS <br />CROSS STREET Y,�� Q (M ApN 1/ 4!- L ZS PARCELS. I- � LAND USE APPLICATION # <br />OWNER NAME �I/,VY�Il Ril V -I, �1 �' QJ /I Yl(�� PHONE --I�)— o.s�r <br />OWNER ADDRESS I I00f 4 E P`Y'�t' C_�•G��(] CRY/STATE21P UY-'kir) C A5--� LiC <br />CONTRACTOR frItzaYmns W'A ls�c-.VYI.� `T� PHONE�_�2L)q'1-C(31 -S40 <br />CONTRACTOR ADDRESS _ 21120 W 11(yg Qjj CITY/STATE/ZIP �Ur . (Z \ <br />SUBCONTRACTOR PHONE <br />SUecoNTRACTOR ADDRESS CITY/STATE21P <br />LICENSE -57 C-61 _ D-09 Other NuNeER t�el?322hq- E.PIRATION DATE <br />GEOGRAPHICAL INFORMAT)ON: CDOrdirudet X Y Townahio Rannw recti <br />on <br />W --Mm Use esllrJPrivate '� InigationlAgrindtural Industrial C Water Quality Monitoring ❑ Soli Sampling/Characterizalm <br />Public Water System <br />H d"N"rit Imm Owren: am Gantad Name w Vrore Nurrbw <br />r TM uP rrorec J NeW M/SII .. Kepiacernent Well - Well Alteration/Modification D Other <br />7 Monitoring Wells) Ill = Shc Borings) t of Eork9s C Geotechnical * dEairw <br />7 Out-Of-Serv(caWell C Out -0f -Service Well Renewal D Cross -Connection Repair <br />i <br />I . <br />Drilling Method C Mud Rotary C Air Rotary :: Auger D Cable Tod - Push Point C Other <br />Proposed Well Depth ft Excavation in diameter _ Open Bottom -I Gravel Pack/Gravel Size in diameter <br />COf1duCtqr Casing in diameter l Conductor Casing Depth it <br />Well Casing Diameterin Thidmess/Gauge/ASTM Shced ; Steel .tic -1 Stainless Steel C Other <br />Grout Seal Depth It Neat Cement (94 lb bag/5-10 gal water)C Sand Cement sack urian water <br />--= 0enton1te (20% solids) C Other <br />Grout Placement Method __ Pumped j Free Fall C Other _ Retardant /Accelerator (name) <br />PEDESTAL Instalied By 7 Driller L Pump Contractor _ Other <br />C Concrete Pedestal Dinert:bnc: Width R Length ft Thick In C Christy Boz C Stove Pipe <br />PSP N Submersible? Turbine = Other HP Pump Set ft StandingWater Level ft <br />I HEREBY CER THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 8E DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REWIRED LICENSE LS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />IMUM <br />OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGN TITLE �.P�ULJK/` DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />1. Date <br />Area Employee ID# s�/r� <br />7� <br />E, SPECIAL. Well Permit <br />WAIVER Received <br />Constructed Well Depth_ <br />PE <br />Codes <br />SC <br />Int. <br />Received <br />B <br />ChecM <br />Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request <br />` 53 r,t) - <br />L' S'2oo� S <br />Erle 63Ae WELL •PUMP PERMR <br />67x04 <br />