Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN CrWf""SVIRONMENTAL HFALTH DEPARTMENT 186E EAST HATELTON AVENUE-STOCKTON CA 9522 =(209)468-34'10 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ;ZZyell— r ('dt CIn/ZIP_�,¢1'lt--L �. <br /> CROSS STREET ,�, q,��1 / APNN,,.-� — y't q�k�..��--PARCEL SIZE M_LANO U E,�r <br /> A,PPUC-ATIO�NN <br /> OWNER NAME s1L�1 yF:��") f 1"�J .—___—..,..LA' PHONE 7L�i!"4-f- <br /> '.+..'72t� 7, w <br /> OWNER ADDRESS .., iaJy„ j yi �y "FV ,.,It..✓� y�4'�} CITYI`S�T-A-7FJZiP G�y 53-- <br /> 3--' <br /> CONTRACTOR JYjf���/y/�/. '�^• �✓Y/" s�C� "'°,✓L�r”, C3`/�/C <br /> CONTRACTOR ADDRES � ClTY1STATEJ7jP PryHO7NFE_/✓7�G,!/A <br /> SUBCONTRACTOR PHONE' <br /> f <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP._ <br /> r <br /> LICENSE -57 1 ❑D-09 ❑OtherNUMBER 1 (J � EXPIRATION DATE.., <br /> DOMESTIC WELL SAMPLING;❑General Mineral/Coliform Bacteria(4391)❑Dibromochioropropane(4392)[]Arsenic(4393) <br /> INTENDED USE omestclPrivate ❑Irrigation/Agricultural []Industrial []Water Quality Monitoring ❑SoilSampiing/Characterization l <br /> ❑Public Water System <br /> If different tram Owner. --Natei-S' -...TTs <br /> ....._ -"—'�bntacTi�a"rrie"oTPfioria"'NumGer <br /> TYPEOFWORK ;*Newwell ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Weii(s) #of wells ❑SollBonng(s) fotbmmg$ ❑Geotechnial #or bos <br /> ❑Out-Of-Service Well ❑put-Of-Service Well Renewal <br /> ❑Cross-Connection Repair <br /> Ci New Pum2 0 Pum acament 0 Pump Repair []Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method,(Aud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth_ ft Excavation I Z- in diameter ❑Open Bottom--CWravei Pack/Gravel Size-7-1-11—in diameter <br /> []Conductor Casing in diameter / Conductor Casing Depth__ ft 7— <br /> Wall Casing Diameter n TtY Gauge/ASTM Schetl ❑Steel ❑Plastic <br /> C1StainiessSteel ❑Other <br /> {Grout Seal Neat Cement(94 lb ba9/5-10 gal water) and Cement_ sack mu/7 gal water <br /> j Ll , ❑Bentonite(20%solids) []OtherGrou,P ❑Pumped ❑Free Fail ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL installed By L❑Driller UPump Contractor ❑ Other <br /> C3Cancrete Pedestal ansions Width it Length h Thick ux n []Christy Box ❑Stavo Pipa <br /> PUMP ubme sibie❑Turbine ❑Other HP_ pump Set ft Standing Water Level =`7t <br /> 1 HEREBY C TIFY 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 /> MIN RE NOTICE REQUIRED FOR INSPECTIONS LEASE CALL(209)953-7697 <br /> SIGNED ✓ � '"� TITLE G '' `�� "' DATE ( <br /> 77-7 <br /> 164 <br /> 1 � I <br /> wo <br /> i <br /> O <br /> t VI I It 4 <br /> A Z <br /> 4 <br /> T,F17 <br /> I <br /> a <br /> I <br /> J;�l�� DEPARTME T U £ L <br /> A ;N-Ptio;,rc^,.e.'te!-0 ByH r'^•� n.re� L3 .,.__..,W ,I+t�, ,)n,4.ot• r i;vP��'fit}Y Jt✓ <br /> ...... _ ....,_ 111 <br /> Grout inspection By Llaie <br /> ❑ SPECIAL Well Permit <br /> Pump Inspection By I Date © WAIVER Received <br /> Soil Boring Inspecti B <br /> COMMENTS y Date / Constructed Well Depth ft <br /> - � �, <br /> PE SC Received Check#/ Amoun! <br /> PermitJ --� <br /> Cod Remit <br /> Info B Cash ted Date Service Re oast# invoice# Wail ID# <br /> °} G <br /> v <br /> i <br /> EHD 43.06 81(11178 <br /> WELLIPUMP PERMIT <br />