Laserfiche WebLink
;mLn,� 2I({•°°� q l���� C - I13��22 <br /> YlJ✓ 6 � / <br /> WELLIPUMP PERMIT <br /> SAH JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1566 EAST HAZELToN AVENUE-STOCKTON CA 95205-6212(209)466-3420 <br /> NON-REFUNDABLE PER IT www.sigov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> Joe ADOREe1F0 Q 1U <br /> CITYfbP y <br /> CROSS STREET l I AIN 4`.Rc.ELSIZEe"d66V SE APPLICATION B o <br /> OWNER NAME }�qONE <br /> OWNER ADDRESS �/ • ' CrTYfSTATEILP <br /> CONTRACTOR L PHONE • / G <br /> CONTRACTOR ADDRE CrrYfSTATE/ZIP /I <br /> SUBCONTRACTORICONSULTANT PHHOON <br /> SUBCONTRACTOR'CONSULTANT ADDRESS114MIT`r�(�r11 P p-f - <br /> LICENSE �/C-57 C-61 D-N Other NUMBER U_�T PIRATION DATE <br /> IN <br /> BILLG PARTY: OWNER CONTRACTOR SUBCONTRACTO NS L <br /> DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria(4391) Oibromochloropropane(4392)_Arsenic(4393) <br /> INTENDED USE _ <br /> Domestic/Private Imgabon/Agricultural - Industrial Water Quality Monitoring Sod Samong/Characterization <br /> Public Water System <br /> it OMren1 Iran 0w . Water System Neme CWa Nemo a Piwne Nimbi <br /> TYPE OF WORK - New Well - Replacement WellM Ahertf ion Other <br /> Monitoring Wells) for wesI Bors)ig,2116hi-rip-rip .f,,,C tical s on b—pa <br /> Out-Of-Service Well Of-S enewal Goss-Connection Repair A <br /> Now Pump Pump Replacement .Pump Repair _Raise Wal Casing / YMEAI <br /> WELL CONSTRUCTION •/C I Y <br /> Drilling Method 9 Ratary Air Rotary /K get Cable Tool Push Point Other ECEIV ED <br /> /��y i <br /> Proposed Wail R Excavation In diameter _ Open Bottom Gavel PatldGravel Size In diameter <br /> and Casin In diameter / Conductor Casing Depth It P O ^0 <br /> Weill Casing Diameter Q.Ai ess/Gauge/ASTM Sched Steel _ Plastic Stainless Steel _ Other L 20 <br /> Grout Seal Oepth�' '(Neal Cement(94 1b bagrS 10 gal water) -.Sand Cement sack mrx/7 flay <br /> Bentonile(20%solids) Other ROU)N COUN-(-Y <br /> Grout Placement Method Pumped Free Fall 0 _ dant/Accelerator(name) H DEPq R T'4 L <br /> MENT <br /> PEDESTAL Installed By - Driller -Pump Contractor - Other <br /> Concrete Pedestal_Dimensions:Width R Length A Thick In Christy Box Stove Plpe <br /> PUMP - Submersible- Turbine .:Other HP Pump Set R Standing Water Level A <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL 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 COMP ANCE WITH ALL <br /> WORKERS COMPENSATION LAWS- <br /> MINIMUM 48 HOUR A NCE NOTICE REQUIRED FO INSP�/C NS-PLEASE CALL(20 9) 3- 97 <br /> SIGNED TITLE 0• fol&CV�� DA �C� <br /> DEPARPENT USE ONLY 1 <br /> Application Accepted By L L� Date - y �`� Arae 3 / Ernpbyee IDS <br /> Grout Inspection By Date _ SPECIAL Well PerlTTit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By / 'U'It Si->j�lK - Date Constructed Well Dept tt <br /> COMMENTS <br /> PE SC Received Choc11W Amount Date Permit/ Invoice Y Well IDS <br /> Codes Into pyn Casb Remitted ervlce Rs uesl0 <br /> Lis 7J Is-0 3► l I ZiJ ' <br /> E/C11ik L111214 • YIELLRII <br /> 92PERNn - <br /> 113 -9 T7 G�-�� �r�C2/l�er,C o�riG C�� afar 7 � � . <br />