Laserfiche WebLink
I. <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN CiotINTYElitymomieNTALMEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERWT 1- www.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> r 'Ta I- tn � V � �c <br /> Jos ADDRESS ` 1 �1 � cmr7TJP .1�C u M yo � C{ .J <br /> CROSS STREET_ 1 t 1�O TT R�0`, APNIOD �Yt�v o PARCEL SIZE LAND USE APPLICATK/1N0 <br /> OWNER NAME A 1'']Z,, U T�• z iPNDNE ?Cl�� <br /> OWNER ADDRESS 3a5 3p5`' `OGl }Un(� N Cy-Ztj CI 1 C.111TATE PU'17C�(� q S�77O(�fv. <br /> CONTRACTOR _• Co \ l 7 r-+ ` \G�,1^]\n 1 /P_HDIE �Cq 7� 1(�-�// / I <br /> CONTRACTOR ADDRESS P.C)- ��L X • r'4 cn lsTAuAD, G n I A- t C^ 1 5 6 3 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSuLTANT ADDRESS CrrY1STAT(E/ZIP <br /> LICENSE N C-57 �61 D-09 Other NUMBER �E 1�I S>� EXPIRATION DATE ? <br /> BILLING PARTY: -1 OWNER CONTRACTOR C SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)!_ Dibromochloropropane(4392)IJ Arsenic(4393) <br /> INTENDED USE DomeStiC/Private !'Irrigation/Agricultural -I Industrial 7 Water Quality Monitoring S Soil Sampling/Characterization <br /> Public Water System <br /> If dMererA from Omer. WA.,System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well Replacement Well ❑Well AfterationlModification r Other <br /> ❑Monitoring Well(s) A o/wells SWI Boring(s) a olbunngs -:Geotechnical a or bohngs <br /> !_i Out-Of-Service Well Oul-Of-Service Well Renewal i"Cross-Connection Repair <br /> 'r ew Pump Pump Replacement [;Pump Repair Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method ?k Mud Rotary Air Rotary Auger J Cable Tool li Push Point .! Other <br /> Proposed Well Depth ii.;('. ft Excavation ).�. in diameter Open Bottom )�Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter (;-,_in Thickness/Gauge/ASTM Sched(1 )(.'C C Steel '2�Plastic Stainless Steel Other <br /> Grout Seal DepthI( C, _ft -i Neat Cement(94 lb bag/5-10 gal water) '71 Sand Cement (' > sack mixR gal water <br /> Bentonfte(20%solids) i.Other <br /> Grout Placement Method umped n Free Fail Other Retardant t Accelerator(name) <br /> PEDESTAL Installed By ler _i Pump Contractor Other <br /> --- <br /> I, Concrete Pedestal CDlmensions:Width J ft Length R Thickin liChristy Box n Stove Pipe <br /> MP ?^Submersible Turbine 1Z Other HP J Pump Set err > If Standing Water Level <br /> 1 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. 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 /> MINI J�A/ 'i HOUR ADVANCE NOTIC5i P,EQUIREE!�FOR INSPECTIONS-PLEASE CA`_!(209)1953-7697 <br /> SIGNED DE.+ TITLE G C a r DATE <br /> rn <br /> r w <br /> PAYME <br /> RECEI d <br /> j <br /> OCT 0 6 I <br /> gAN JOAQUIN <br /> ENVIR0NM <br /> HEALTH DEP = 1 <br /> P/CRTMENT U <br /> Application Accepted By ''ff Date Area-� Employee Ilh%�`� F� <br /> Grout Inspection By ''lr_ .i 4 0 '� s�.as' Date LLljiI7 D'Z,1 L SPECIAL We11 Permit <br /> Pump Inspection By Date WAIVER Received <br /> SWI Boring Inspection By D to Constructed Well Depth <br /> COMMENTS <br /> PE SC Received Check*( Amount to Permft/ Invoice A Well IDA id <br /> Codes I o Cee Re d Service R uesta <br /> t <br /> I <br /> ..11-06 611tY.'019 � /32-7 73 U�I <br /> WELL RUMP PERMIT <br />