Laserfiche WebLink
WELL/PUMP PERMIT b 1309 . Go v>�� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'12 FL-STOCKTON CA 95202 -(209)46&3420/ <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J p L•h a G /G'f� ff�1 CITv/ZIP pC.1 'tiCi7 ✓ 'r <br /> APN J 0 8 0�--� P.�t SR Y.AND USE APPLICATION# <br /> CROSS STREET 1 r z <br /> OWNER NAME �M,f I,t,d S �.�R i• Q _ PHONE <br /> ( <br /> OWNERADDRESS (0IIt- CITY/STATFIZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESSl� }/.� f ,• CITY/STATE/ZIP L(P ? <br /> SUBCONTRACTOR�'�`�'l�`P'`" PHONE <br /> SUBCONTRACTOR ADDRESS Z-$�-S F. NLy, I�f It% CITY/STATE/ZIP-54A '75 za� <br /> LICENSE A(C-57 LI C-61 ❑D-09 D Other NUMBER '40'LS Z EXPIRATION DATE /Z 3/ 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE ❑Domestic/Private D Irngation/Agricultural D Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdiffermtflnm Owner: W.. ystem .— ontact ame or ne u <br /> TYPE OF WORK D New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> N of borings qa GeotxhniC81�0 of bonngs <br /> 13 Monitoring Wcll(s) #of wells eiMiBatiag(s) <br /> O Out-0f-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary )dA u er ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth I 0 R Excavation yT in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sizcin diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schell ❑Steel ❑Plastic ❑Stainless Steel Q O er <br /> Grout Seal Depth ft O Neat Cement(94 111 bag/5-10 gal water) F Sand Cement h �'�,tr,s k mU/7 gal water <br /> ❑Bentonite(20°/solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor D Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Bos ❑Stove Pipe <br /> 1M ❑Submersible ❑Turbine D Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED &d CIMA I TITLE � � ( GS S �i.nls(� DATE <br /> n� <br /> C Lj <br /> r <br /> O Q <br /> 5 <br /> DEP RTMENT U E O LY �pf>h <br /> Application Accepted By Detc 3 410r Area Employe ID# I <br /> Grout inspection By Date ❑ SPECIAL Well Permit �Q <br /> Pump Inspection By Date ❑ WAIVER Received / <br /> Constructed Well Depth H <br /> COMMENTS /4k—(�S—,G,+4'7� -r LimiL LTKU 15 5; lit rti1.6J4 <br /> PE SC Received heck#/ Amount Permit/ Invoice# Well 1D# <br /> Codes Info By RemlHed Pal I Service Re nest# <br /> d U LUKi��5ee-7 <br /> END 43-07-006 WELL PUMP PERMIT <br /> 1/2712005 <br />