Laserfiche WebLink
Ii <br /> II WELL TPUMP PERMIT <br /> !I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3a°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT .i� CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED Lin <br /> 7 qS�Sv11Er 0D. <br /> JOB ADDRESS t`IiA�IL0 V- M�� CITYIZIP :]'CO C-�T o a 1 y5 Z0� <br /> a <br /> - Ir�'LAND b <br /> CROSS STREET iQ\ Q.� '(LiV fir`- APN \'13 Qy U .._PARCEL SIZE'51Z-1-1 USE APPLICATION# <br /> OWNER NAME SVA0.u+ r-_ PHONE <br /> p <br /> CITYISTATEIZIP ��b .� al0 L1 95 1,0 <br /> \.c -OWNER ADDRESS <br /> � <br /> h ' <br /> CONTRACTOR , ��`tZ�O P rSSt]t 1 l GS _. PHONE <br /> i IM <br /> CONTRACTOR ADDRESS A -L �C� S'CCZ��I. y.IY�" CITY/STATEIZIP %-0 A SI-40 <br /> SUBCONTRACTOR I� PHONE <br /> ii <br /> SUBCONTRACTOR ADDRESS l CITYISTATFIZIP <br /> l ko 0 0 <br />� LICENSE C-57 ❑C�1 � ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private: ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: ater System Name P. a SB am e u <br /> III <br /> TYPE OF WORK ❑New Well El Replacement Well ❑Well Alteration/Modification [❑Other <br /> ❑Monitoring Weil(s) #of wells PoilBoring(s) t3, ftP&rnit may h&4�. ;"G�`$u u1G 41 Lt borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewalo <br /> wo�F����r,"..ff"fed or inspected. <br /> ❑New Pump Pump R lacement ❑Pump Repair n <br /> WELL CONSTRUCTION I! Dy Erivlronmr L.-al HealthivIslon <br /> Drilling Method ❑Mud Rotary `!O Air Rotary ,Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth it) �,� ft Excavation k6 in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft f <br /> Well Casing Diameter in'� ElThicknesslGauge/ASTM Sched ❑Steel 13Plastic ❑Stainless Steel ❑Other it <br /> Grout Seal Depth ( ft Neat Cement(941b rag/5-10 gat water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name S Q%%.- UUx'CTtN(,-.S [3Specs on File 13 Specs Submitted <br /> Grout Placement Method ❑Pumper ree Fail ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor Other <br /> ❑Concrete Pedestal Dimensions:WidthLength ft Thick in ❑Christy Box ❑Stove Pipe r <br /> PUMP ❑Submersible ❑Turbine ❑Other - HP p et ft Standing Water Level ft m <br /> PREP D 1 TION WP <br /> D I A S <br /> JO U COUNTY RDIN E AT W AND LES AND GULATION I SOT T Y RE 1' LICENSE S <br /> C A I CON CTORS S ENSE RDI A <br /> WOR COMPE ATI LA <br /> ! U 24 O AD NCE NO E OC <br /> SIGNED I� TITLE <br /> V� _Gt.►G. - .�DACE- <br /> • - SOUTH PARK - — T E VItill <br /> II.} <br /> I _ UNIT NC 1 _ _I U IT N <br /> -2 <br /> MADRID -.. 1 <br /> PARK LOT (E) <br /> 7 <br /> PARK LOT - <br /> _ .�,� - - �.,._ - ,.�..-,mar-.•yrrr '. " '� <br /> Pr 2f <br /> s <br /> A <br /> PARK LOT- (E)`� <br /> IV BR4PdBEav RAEJAIET <br /> . ! <br /> --TERRACE._ _ <br /> 38 45 <br /> Ir DEPARTMENT USE ONLY <br /> �Date�:1- - s3_�: �o�1 y' QArea ,� ems" .Employee•ID# <br /> Application Accepted By-=� `_ - <br /> s Grout inspection By �I Date ❑ SPECIAL Well Permit <br /> Pump Inspection By a Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> I PE SC Received Chec Amount Date , Permit/ Invoice# : Well ID# <br /> Codes Info B ash emitted Service Re uest# <br /> WELL PUMP PERMIT _3 <br /> IF EHD 43-02-006 s <br /> U2712005 <br />