Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT lase EAST HAZFLTON AVENUE-STOCKTON CA 95205-6232(209)46"420 <br /> NON-REFUNDABLE PERMIT 1. _www.sigoy.or,g//ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> FCR <br /> �l!;sl�n1 '-pu. 0 S�iI�IVY� CmrclP S`rbc.cc'.MN �ISZO(� IIS <br /> / .. 0 Ts� srl,I,PN [�ao3�0-7 7 CI PARCEL SQE13 tANo USE APPLICATroNor f 0f 57l .+r'W-.• Vri PNONE(z09) 737- Ozz-ij <br /> 5—r��/ /V L pox/4-00 5 CRY/STATEMP :57--6C,4--7-0A C A 95' <br /> (CONTRACTOR ! `41 �V u J�J rY <br /> NE <br /> CONTRACTOR ADDREss .3r��G) //�/^�f�d I D/�� S r CrDrvisTTA�T'EM, 5,01V 0/[�g!&O C,4 Zl Z G <br /> SUecONTRACTOR/CONSULTANT / ) Q)rj L✓ A,,)p W ILr V.5 1 0 AJ S( ea.{A e-7 ���` ]/�/)S y y-3 Z-7 Z <br /> SUBCONTRACTOR/CONSULTAW ADDRESS y.37 I J-L),"PtI{5 HOL£ CfT(T�/STATE/ZIP r-'IL'�'`9'S�/LLE �Jv Z//C � <br /> LICENSE Y: _ DO D-09 .Other NUMBER 5/ 7737 EXPIRATION DATE �C ZZ <br /> BR11NO PARTY: J OWNER L!CONTRACTOR 3 SUBCONTRACTOWCONSULTANT r I <br /> DOMEsTIc WELL SAMPLING:O General Mineral/Coliform Bacteria(4391)7 Dlbromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 2 Domesticli-' to O Imijal on/Agricultural C Industrial C Water Quality Monitoring 7 Sol(Sampling/CharacterizationI <br /> 7 Public Water System <br /> e different hum Owner ater sYalem Nmm Contac me ar nrw um r <br /> TYPE OF WORK i New Well Replacement Well Well AlteratiorVModification ;rOther )G C-T70,n! <br /> Monitoring Well(s) X of wells r Soil Boring(s) a of bcdngs Geolaxdinlcal 0-f <br /> _Out-Of-Service Well L Out-Of-Service Well Renewal a Cross-Connection Repair I <br /> 3 New Pum Pu Replacement ❑Pump RBDair C Raise Well Casino <br /> WELL CONSTRUCTION/ <br /> Drilling Method !'SNud Rotary n Air Rotary ;Auger u'Cable Tool J Push Point D Other I <br /> (Proposed Well Depth !9Z ft Excavation 12- In diameter r'Open Bottom L <br /> 7 Gravel PadUGravel Size in diameter I <br /> Conductor Casing in diameter / Conductor Casing Depth h <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Schad Steel C plastic -)StPr-le----el D Other <br /> Grow Seal Depth /00 R C Neat Cement(94 lb bag3-10 gel water) Sand Cement_ 10, <br /> sackmrxllgaiwater <br /> Bentonite( %solids) n Other - <br /> [,rout Placement Method umped -Free Fall Other Retardant/Accelerator(name) <br /> P DESTAL Installed By .-,Driller C Pump Contractor ,D Other <br /> Concrete Pedestal ODlmenslons�Width <br /> tt Length ft Thick In C7 Christy Box �Stove Plpe <br /> i <br /> PUMP Submersi6leO Turbine 0 Other HP Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> MU/NIM O}�R//jjA,V NCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL(209)953- 697 <br /> SIGNED (it� V/ TITLE SPF'/ 'nc^IS IH,4dV,� <br /> �MPv <br /> F��FO <br /> 3,2 <br /> c <br /> i RToL/NTr <br /> q <br /> r�ENt <br /> DEPARTMENT USE ONLY 1 /� <br /> Application Accepted By ate_� �� ..�/ _ Area.3 5�`Ti f��Employee IDp <br /> Grout Inspection By L{ Data j t( ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soo Boring Inspection By Dale-1---��--- Constructed Well Depth <br /> it <br /> COMMENTS v :y -I-'�drr/`'9 "A <br /> P Rel: ec Amoun -- orml -- -- <br /> Codes Nrfo ash Remitted aa Service Re ua Ill Invoice X Well IDX <br /> I — <br /> I � <br /> ENO4106 6m Mete <br /> n�/�� WELL(PUMP PERMIT <br />