Laserfiche WebLink
V <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 12091 AAA-Ullr <br />NLON-KEFUNDABLE PERMIT wwW.s' ov.orglehd EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS Z )Cn, t 1 criYrLIP �_ c h� C1 -12- L1 C' <br />CROSS STREET / APN D � O O PARCEL SIZE 11 • C LAND USE APPLICATION . <br />OwNER NAME 1 ' \ _ C L PHONE ZO'\ Li C (C ' I j <br />OWNER ADDRESS I O Z Q 1A JI—e— C' -I f t• C, .'I CITY/STATE/ZIP L -C Ck 1 v1 Z Ci <br />CONTRACTOR J )_ G, r ✓� Ll 'Yl X51 i ric PHONE Z C. Cj ' j % r'1 ,• ZC% C C <br />CONTRACTOR ADDRESS `, �\� `1 �., , ,: A CITY/STATE/ZP <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE C-57 (C <br />BILLING PARTY: OWNER <br />D-09 <br />CITY/STATE/Z1P <br />Other NUMBER 22&ko EXPIRATION <br />CONTRACTOR ; SUBCONTRACTOR/CONSULTANT <br />UUMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) DibromnrhIomnrnnana 1d3Q91 re �Qo <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If dlff rent from Owner Water System Name Contact Name or Phone Number <br />- - - •..... .. c�� r.e Nlet,CIllClll VVCII <br />Monitoring Well(s) #of wells <br />Out -Of -Service Well <br />VVell Alterationimodlticatlon Other <br />Soil Boring(s) s of boriigs Geotechnical <br />Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depthft Excavation in diameter Open Bottom Gravel Pack/Gravel Sizein diame <br />' Conductor Casing in diameter / Conductor Casing Depth _ft N;� <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixr7 gal wat6 <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensro ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set a Standing Water _ e 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 C049PENSATION LAWS. <br />/NUNIMUM 48 HOUR ADVA/•r/(y/���0(6TICE REQUIRED FQR INSPEgTIONS - PLEASE CALL (209) 953-7697 <br />SIGNCb f.: �/ b �� /'ITLE ,��t/ DATE <br />RF SMF <br />cF jV �T <br />7�l 0 <br />6202 <br />Rp�IN?? <br />DEpq Coo <br />R MFNT Y, <br />4—✓ <br />DEPARTMEk4-14SE ONLY . ),// <br />Application Accepted By L L Date 1 �S LIT Area < C� Employee ID# F{ 7 Irlk C"I <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date l i i WAIVER Received <br />Soil Boring Inspection By Aate Constructed Well Depth It <br />COMMENTS <br />1AMON—FaME, <br />M" <br />Da <br />Permit/ <br />Service Request # <br />F/104AFMC-15 RM <br />WELL (PUMP PERMIT <br />