Laserfiche WebLink
r ` y <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CrTYZ�P'�j 3 m <br /> CROSS STREET "APN201- 100-050 /J7.yy� PARCEL SIZE LAND USE APPLICATION# o <br /> OWNER NAMEas I r 1 _ MN G-) ����iA/� f� 01/ N <br /> PHONE tis--F' �"!V VOV�/ rn <br /> OWNER ADDRESSV'Q CnYISTATE/ZIP 1 V I CJA <br /> CONTRACTOR Ka- Q11K DY-1111W N <br /> PHONE <br /> CONTRACTOR ADDRESSAlwCrTY/STATE/AP IIIA q��jr�Z_ <br /> SUBCONTRACTOR PHONE b/-=`'-- <br /> SUBCONTRACTOR ADDRESS CITY/STATKZIP <br /> LICENSE -57 0 C-61 0 D-09 D Other NUMBER W, ExPIRATIGN DATE •'/O•�� <br /> DOMESTIC WELL SAMPLING:p General Mineral/Coliform Bacteria(4391)AO Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Dome5brJPrivate 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If ditlersnt from owner: Water System Name Contact Name or Phone Numl»r <br /> TYPE OF WORK New Well IX Replacement Well 0 Well Alteration/Modification 0 Other A M�` , <br /> 0 MonitoringWells #of wells 0 Soil Borin s #oI borings e or bongs C �•I ry <br /> O 9O 0 Geotechnical I <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair k/q <br /> 0 New Pum 0 Pum Replacement 0 Pum Repair 0 Raise Well Casing (J <br /> WELL CONSTRUCTION ]` <br /> Drilling Method Mud 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 11 Other I 2020 <br /> IT, <br /> Proposed Well Depth Rota 1 ft Excavation_lT in diameter 0 Open Bottom Gravel Pack/Gravel Siz in is q Q <br /> 0 Conductor Casing in diameter I Conductor Casing Depth J` ft yEq�T ENTAL COUNTY <br /> rY <br /> Well Casing Diameter, ss/ <br /> in, Thickness/Gauge/ASTM Schad 7, 0 Steel Plastic 0 Stainless Steel I I Other <br /> Grout Seal Depth ft 0 Neat Cement(94/b bag/5-f0 gat water) 0 Sand Cement sack mix/7 gal water R rMEN] <br /> Bentonite(20%solids) 0 Other <br /> Grout Placement Method Pumped 0 Free Fall 0 Other 0 Retardant I Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODimenslons:Width ft Length ft Thick In 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersibie0 Turbine 0 Other HP Pump Set ft Standing Water Level ft <br /> ANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> WORKERS COMPENSATION LAWS. <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT IAM IN COMPLIANCE WITH ALL <br /> MINI O VANCE NOTICE REQUIRED FOR,INSPEC IONS-PLEASE CALL(209)9(5�3-76/97 <br /> SIGNED TITLELIM/1"10NME DATE,U•�`Q• <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By --e---10/1� _ Date- t7�� tT�Q <br /> �? l Area Employee ID# r' <br /> Grout Inspection By !/yL rtGl.l' J "' ;'i�1�_' ata ��j v <br /> ❑ SPECIAL Well Permit <br /> Pump Inspection By Date <br /> Soil Boring Inspeclion By ❑ WAIVER Received <br /> COMMEN Date Constructed Well Depth ft <br /> �` ` - <br /> :t.t IEOL <br /> r71 k <br /> PE Sc Received Cho k#/ Amount <br /> Codes Info ash Remitted Date Permit! <br /> 310 C <br /> Service Re Lest# Invoice# Well ID# <br /> J 2G% <br /> JSP I Cris Q L 5 <br /> O <br /> ' <br /> E!1043-06 841/18 <br /> � /'j�(///�l C�f—•� WELL'PUMP PERMIT <br />