Laserfiche WebLink
WELL 1 PUMP PERMIT i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 32°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> t/ �_r q � <br /> JOB ADDRESS CITYIZIP; i-1 VYy f y <br /> d <br /> /� / /3 LAND USE APPLICATION# <br /> CRDSS STREETlrn ICtC. PIN• APN �— O~ PARCEL SIZE �y <br /> OWNER NAME DlTV :—= PHONE <br /> � <br />` OWNER ADDRESS L CITYISTATE/ZIP j l IJC U^j r t� <br /> k o N PHONE (� 1— J� T~ 3-4-0� — <br />` CONTRACTOR • ` ^ ��7" �,f <br /> CONTRACTOR ADDRESS TNbU�TY1 ! + CITYISTATEIZIP—60 <br /> S C--d� 1 ~ <br /> SUBCONTRACTOR PHONE <br /> CITYISTATEIZIP <br /> SUBCONTRACTOR ADDRESS /!� j} f G <br /> LICENSE gC-57 [3C-61 ❑D-09 ❑Other NUMBER 6 00L EXPIRATION DATE 6 -0 <br /> k GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> r INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑ JVjjj n i! 1 to tion <br /> ❑Public Water System <br /> If different from Owner: aterSystem Name ontatt Name or P orte um r <br /> e without <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Mo cation Ot er- <br /> w4Steing ro � � ens e� np <br /> ©Monitoring Wel1(s) #of wells �5oil Boring(s)� ,� ! <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal bQ,[,mft �i�'"�s WrHeallh Division G <br /> t ❑New Pum ❑Pump Replacement ❑Pump Re it <br /> t WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary kAuger 13 Cable Tool 11 Push Point ❑Other <br /> { Proposed Well Depth w�ft Excavation �2 _in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> C ❑Conductor Casing in diameter / Conductor Casing Depth ft C1. <br /> t Well Casing Diameter in ThicknesslGaugeJASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth R ❑Neat Cement(94 lb hag 15-10 gal water) ❑Sand Cement sack mix/7 gal water l <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted l <br /> Grout Placement Method ❑Pumped Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor <br /> ❑Concrete Pedestal Dimensions:Width ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other P Pump Set ft Standing Water Level ft <br /> �~ I 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 /> ADVANCE NOTICE REQUIRED FOR <br /> FFOR INSPECTIONS r <br /> SIGNED TITLE N�C�2� DATE ,`fir 016 <br /> 17- <br /> ]F:T­I[-tD <br /> 3970 WIT-COX ROAD - <br /> S'I'OCK'I'ON. CALIFORNIA i��il, I <br /> l�l <br /> E [ E TA <br /> L <br /> j <br /> HEAL rH PE A <br /> I _..... .."•;:;, 1 ti.S�.l'j� � til <br /> i -- - <br /> � - v <br /> d <br /> -... <br /> '13 P-A`R T [VI'E N T" U"S E-O N`L Y _ <br /> r Application Accepted By Date Area Employee ID# l5 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well De th ft 1 <br /> COMMENTS <br /> PE SC Received (Ch eck#I Amount Date Permit/ Invoice# Well ID# <br /> Codes Info as Remitted Service Request# <br /> t <br /> ERD 43.02-006 WELL PUMP PERMIT <br /> 1/2712005 <br />